Family Physician Statement - Form C
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1PNB MetLife India Insurance Company Limited. (Insurance Regulatory and Development Authority Life Insurance Registration No. 117)
Registered Office: ‘Brigade Seshamahal’, 5, Vani Vilas Road, Basavanagudi, Bangalore - 560 004, , Fax: +91-80-4150 6969
Family Physician Statement – Form C
Name of the deceased / patient
Address of the deceased
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□
Age
Gender
Male
Female
□
□
Are you the family doctor of the above
Yes
No
Patient known to me since _________ Years _______ Months
deceased? If “Yes” please provide duration
Was the deceased referred to you by any other
doctor? If “yes” please provide details
□
□
□
Has this patient, to your knowledge, used
Yes
No
Don’t Know
Details: ___________________________________
tobacco products, alcohol, narcotics?
□
□
Do you have copy of med records / OPD notes?
Yes
No
If “Yes” please attach a copy of the same with this statement
Details of Consultation in last 5 years:
(1)
(2)
(3)
Date of Consultation:
Patient presented with
complaints of
Patient having this complaint
since
Name of the tests advised by
you
Dates on which tests were done
and the results
Name and address of the
laboratory where the tests
were done
Diagnosis made by you
Treatment / medication given
by you
DECLARATION:
The above statements are true and complete to the best of my knowledge and belief and as per the records maintained by hospital/ clinic:
Signature of the Physician
Name of the Physician
Qualification of the Physician
Regd. No. of the Physician
Contact No.: Physician/ Hospital
Email id of the Physician
Physician/ Hospital Seal
Date:
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Contact our Toll Free No. 1800-425-6969 for any queries or write to us at
indiaservice@pnbmetlife.co.in
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