COSMETIC SURGEON INDIA
 
 

CONSENT FORM

ASHIRWAD HOSPITAL

1 - Ashirwad Enclave,
Ballupur,
Dehradun 248006,
Uttaranchal,
INDIA

Fax +91 135 2764600

email: cosmeticsurgeonindia@gmail.com

 

AUTHORIZATION FOR COLLECTION OF FEE THROUGH CREDIT CARD

 

Kindly charge my credit card (details given below) a sum of Rs 4500/= (Rupees  Four Thousand five Hundred only) as advance for incidental charges and the transportation from New Delhi Airport to Ashirwad Hospital, Dehradun.

 

Name as on Card                     ………………………..

Credit card type                       VISA  / MASTERCARD

Credit card number                   ----  ----  ----  ----

Date of expiry of card               mm/yy

CVV No.                                 - - -

Date of Birth                             dd/mm/yyyy

 Thanking you

 

(Signatures)  

Name

Email address

Full Postal Address

 

 

Date

 

 

For any query at all, please feel free to write to us. We shall respond at the earliest

1.  Ashirwad Enclave, Dehradun - 248 006, Uttaranchal (INDIA) Tel: +91 (135) 2763600, 2764600
E-mail cosmeticsurgeonindia@gmail.com

www.cosmeticsurgeonindia.com