Please fill out the form below and we will respond to you at the earliest.

* indicates required fields

Fields marked (*) are cumpolsory
Name of the Patient: *
Gender: *
Male   Female
Name of the Hospital
Location: *
Date of Admission: *
Date of Discharge: *
Total Amount of Bill: *
Hospital Contact Details
Full Address of the Hospital : *
Pincode: *
Complainant Details
Name of the Complainant: *
Address of the Complainant : *
Mobile: *
E-mail: *
Relationship of the
Complainant with the Patient: *
Complaint Details
Name of the Treating Doctor: *
Nature of Complaint : *
Details of the Complaint: *
Please attach scanned/soft copies of the relevant documents:
Verification code for security
Enter Code: *

Note : This form is optional. You can also directly lodge your complaint by sending us email at Please provide complete details in email.


Su Mo Tu We Thu Fr Sa