Garapati Moshe Memorial Trust | We Work for Good Health

Patient Information

Full Name

Phone Number

Education Details

Do you have educational details? (Optional) Yes

Employment Details

Do you have employment details? (Optional) Yes

Supporting Documents

Please upload clear, legible copies of all relevant documents. Maximum file size: 5MB per file. Accepted formats: JPG, PNG, PDF.

Medical Reports/Diagnosis Documents * Upload medical reports, diagnosis documents, or treatment plans.

ID Proof (Aadhar Card) * Upload a clear copy of your Aadhar card.

Medical Bills/Quotations * Upload bills, quotations, or cost estimates from the hospital/clinic.

Additional Supporting Documents Upload any additional documents that support your request (e.g., income proof, bank statements).

Other Relevant Documents Upload any other relevant documents that may help in evaluating your request.

Requestor Information

Your Name

Relationship to Patient

Your Phone

Your Email

Preferred Contact Method

Preferred Contact Time

How did you hear about us?

Bank Account Details

Please provide your bank account details for receiving funds if your request is approved.

Bank Name

Account Number

IFSC Code

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