HOME QUARANTINE PACKAGES

Home Care Quarantine Package Form

Patient Name

Age

Sex --Select-- Male Female

Postal Address

Email Id

Whatsapp Number

Referring Doctor

Package (14 Days) Home Care Quarantine

Terms & Conditions Decline Accept

Package Amount in Rupees

Mode of Payment: Online Payment Cheque/DD No NEFT

Bank Name:

Cheque/DD no.:

Reference No.:

Consent: Stay in a well-ventilated single-room preferably with an attached/separate toilet. Maintain social distancing with all persons.
Needs to stay away from elderly people, pregnant women, children and persons with co-morbidities within the household.
Restrict any movement within the place of stay.
Under no circumstances attend any social/religious gathering e.g. wedding, condolences, etc.

Accept & Submit Decline

For NEFT
Name of Beneficiary: Indian Spinal Injuries Centre
Name of Bank: ICICI BANK LTD
Bank Account No: 000701002650
Branch Address: 9A, Phelps Building, Connaught Place, New Delhi 110001
RTGS/NEFT Code: ICICI0000007