If you know someone who needs medical aid and who cannot afford it, tell us and we’ll do our best to help. In order to ensure that the truly needy receive our aid, we will require copies of either a ‘Below Poverty Line’ (BPL) card or income certificate.

Your Name

Your Email

Your Phone No

Name of the patient being referred

Diagnosis (if previously examined)

Current Clinical Condition

Case History Documents (Supported file types: .pdf, .jpg, .png, .doc)

Which speciality to be referred to

Contact details