Krishna Heart Insitute,Heart Hospital,Hospital In India,Hospital In Ahmedabad,Medical Tourism

CONSENT FORM - FORMAT

Yes I want to sponsor patient/s and enclosing Cheque/DD no. amount of Bank name .

Name	:
Address	:	</td> </tr> <tr> <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">Phone No</font></td> <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">:</font></td> <td width="31%"><input type="text" size="14" id="phonetxt" name="phonetxt"/></td> <td width="17%"><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">Mobile Phone</font></td> <td width="2%"><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">:</font></td> <td width="37%"><input type="text" size="14" id="mobiletxt" name="mobiletxt"/></td> </tr> <tr> <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">Fax</font></td> <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">:</font></td> <td><input type="text" size="14" id="faxtxt" name="faxtxt"/></td> <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">Email</font></td> <td><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">:</font></td> <td><input type="text" size="25" id="emailtxt" name="emailtxt"/></td> </tr> <tr> <td> </td> <td> </td> <td colspan="4"> </td> </tr> <tr> <td><input type="submit" value="Submit" name="Submit"/></td> <td> </td> <td colspan="4"><input type="reset" value="Reset" name="Submit2"/></td> </tr> </tbody></table> <p align="left"><font face="Verdana, Arial, Helvetica, sans-serif" color="#00468c" size="2">Send an Email OR Print and Fax the above format. For <a href="mailto:info@krishnaheart.org"><strong>Mailing Click Here</strong></a></font></p></td> </tr> </tbody></table> </form> </div> </div> </TD></TR> </TABLE> <div class="footer" align="center"> <div class="footerlinks" align="center"> <a href="index.php">Home</a> \| <a href="about.php">About KRISHNA</a> \| <a href="department.php">Departments</a> \| <a href="doctor.php">Doctors</a> \| <a href="inter.php">International Patient</a> \| <a href="Tourism.php">Enchating India</a> \| <a href="corp.php">Corporate Clients</a> \| <a href="patient_testi.php">Patient Testimonials</a> \| <a href="news.php">News & Events</a> \| <a href="patient.php">Health Awareness</a> <br> <a href="healthcheckup.php">Health Checkup</a> \| <a href="help.php">Emergency</a> \| <a href="trust.php">Divya Jyot Charitable Trust</a></div> <div class="desclaimer" align="center"> Copyright © 2009. KRISHNA Heart and Super Specialty Institute, Ahmedabad, Gujarat, India. <br/> Not to be copied or reproduced in any form or medium, <a href="disclaimer.php"> Disclaimer</a> <br> Developed & SEO by: IT Centre, KRISHNA Heart </div> </div> <!-- End ImageReady Slices --> <script language="javascript" src="js/slide_show_execute.js"></script> <script language="javascript"> $(function(){ // $('div.sidemenubutton').each(function() { $(this).corner("notch 3px"); }); // $('div.sidemenu').each(function() { $(this).corner("tl br 25px cc:#FFF"); }); // $('div.round_border').each(function() {$(this).corner("round 4px").parent().css('padding', '1px').corner("round 5px")}); // // }); </script> <script type="text/javascript"> var gaJsHost = (("https:" == document.location.protocol) ? "https://ssl." : "http://www."); document.write(unescape("%3Cscript src='" + gaJsHost + "google-analytics.com/ga.js' type='text/javascript'%3E%3C/script%3E")); </script> <script type="text/javascript"> try { var pageTracker = _gat._getTracker("UA-9951853-1"); pageTracker._trackPageview(); } catch(err) {}</script> <map name="Map"><area shape="rect" coords="155,12,233,45" href="image.php"> <area shape="rect" coords="78,16,153,48" href="career.php"> <area shape="rect" coords="0,18,73,48" href="index.php"> </map></BODY> </HTML>