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*"HI-TECH MEDICAL COLLEGE AND HOSPITAL
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(Under Vigyan Bharati Charitable Trust) A

Health Park, Rasulgarh,

Phone: 0674-2371406 /07/ Bhubaneswar-751025
08, Fax: 0674-2371409
H-Tech Medical Colege &Hospa www.hi-techmedical.org BEHERHVBC
OPD REGISTRATION CARD DR. P.K.
SENIOR COMsULTANT OF MEDICINE
REGD. DATE :14/01/2021

REGD. NO. 202101140428 PATIENT NAME BIKASH KESHARI JENA

DEPARTMENT GENERAL MEDICINE AGE/GENDER 2 8 YEAR / MALE
PATIENT TYPE REG.WALK-IN/GENERAL ADDRESS MASABARI,NAYAGARH,
ODISHA, INDIA,
REGD. FEES 50.00

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FACILITIES AVAILABLE-
24 Hrs Emergency & Csialty Specialists in all Departments. Laparoscopic Surgery Paediatric Surgery Plastic Surgerye Neuro Surgery
Cmercs&Gynaecology Cosmetik Surgery Orthopaedic Operation Theatres iCU ICCU NICU/PICU Burn Unit- TB & Chest
ENT-Generai Medicine General Surgery Cardiology Nephrology (Oialysis) CTVs Psychiatry Physiotherapy Endoscopy ECHO
Tay Dgtal X-ray CT Scan MRI Blood Bank Pathoiogy Trauma Care Unit Hi-Tech Test Tube Baby Research Centre 24Hrs Pharmacy
24tes Armbulance Service Help Line Number: 1800 345 1212
Peasebring thde card at each vist. This card is valid upto 7days rom date of registration)
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SELFDECLARATION FORM FOR COVID-19 SCREENING C'
SENIOK

(ACCORDINGTO GOVT. OF INDIA GUIDELINES)

FOR PATIENTS IN OPD AND ALL ATTENDANTS AT THE ENTRY POINTS IN THE HOSPITAL)

1. Did you visit any foreign countries in the past 1-2 months? YES/NO-

Ifyes, During your visit, What all cities did you visit ?... ***
*****

****

2. In the past 1 month,during yourvisit to foreign countries, did you :

a. visit any sea food/ animal food market ? YES/NO

b. come in close contact of any person suffering from fever and cough ? YES/NO
C. visit any health facility outside India ? YES/NO

d. Did you have come in contact with any person who had foreign travel in past 1-2 months

YES/NO
3. Are you suffering from any of the following symptoms?

YES/NO
a. Fever

YES/NO
e -
b. cough

C. respiratory distress YES/NO

Ifyes, Duration... eaooe*°°°*°°°°°°ee*°* *°*e°*

NAME.aiKaAa. an.
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ADDRESS.. a . aLar.
**********e°°**e

MOBILE NO:.. ..c ....e**ee****

Email ID f any: ..

Desa/
SIGNATURE OF THE PERSON CONCERNED SIGNATURE OF THE'AUTHORITY
(Note: questlonnalre is subjectto modificatlon by HOD/ treating physiclans.)