Bharosaa - Membership Form

MEMBERSHIP FORM

User Member Information

Primary Member Details

Secondary Member Details

Important Contact Details

Authorised Next to Kin

Emergency Details

Contact Details (Kolkata based Relative or Responsible Friend /Neighbour)

Preferred Hospitals for Emergency Situtions

For Primary Member:

For Secondary Member:

(NOTE : SUBJECT TO AVAILABILITY OF BED)

Health Insurance Details

For Primary Member:

For Secondary Member:

Physician Details

For Primary Member:

For Secondary Member:

Declaration

I declare that I am a competent adult and of sound mind while giving all the information in this aforesaid registration form of Bharosaa.

I declare that I am giving this information in every category of this Registration Form with my full consent and with my free will and without any undue influence from any corner.

I declare that all the information provided by me to the Bharosaa team vide this aforesaid Registration Form is true to my knowledge and believe and I have not concealed any vital information related to my health from the Bharosaa team.

I declare that if there is any addition or alteration or new development in any information whatsoever I will be obliged and it will be my responsibility to inform Bharosaa Team at the earliest with such new information.

I Accept all Terms & Conditions