JP Privilege Card Application

Email.: privilegecard@jaiprakashhospitals.com

JP Privilege Card Application Form

*Application For

New Card

Renewal

*Privilege Card (Choose from the options below)

*First Name

*Surname

*Date of BirthClick to select or type in DDMMYYYY format

*Gender

Male

Female

Others

UHID No. (If Existing Patient)

The Privilege Card will be sent to the following address.

Organization / In care of(Optional)

Designation(Optional)

*Address Line 1

Address Line 2

*City

*State

*Postal Code

*Mobile Number

Alternate Contact Number

*Email

*ID Proof / Address Proof

ID Proof Number(Optional)

Issuing Authority

Central Govt.

State Govt.

*Upload ID Proofe.g. Aadhaar Card or PAN Card etc

*Any pre existing ailments / undergoing treatment fore.g. Diabetes or Asthma

Recommended By ( if any)

Before submitting the request, Please verify the entries done by you. Once you submit, the request will not be editable.

By submitting I hereby give my consent to be contacted by JP Hospital representatives on the given contact number if needed, for further processing of this application.