URGENT PATIENT
SUPPORT

Providing immediate medical assistance and verified fundraising for patients in critical need across the community.

गंभीर रूप से बीमार मरीजों के लिए तत्काल चिकित्सा सहायता और सत्यापित धन संचय सहायता।

Before You Apply

All applications undergo a rigorous multi-step verification process to ensure support reaches those in genuine need.
Your privacy is our priority; all medical records and financial documents are handled with strict confidentiality.
Security Alert: Do not upload or expose your Aadhaar number or sensitive bank details in public story fields.
Verification status is updated internally and visible in your dashboard once you submit your request.
Campaigns are only activated for patients who meet our verified medical assistance criteria.

Urgent Medical Support Request

This form is for submitting a request for urgent medical assistance under the ADIYOGI JNANA FOUNDATION Verified Medical Assistance Campaign. Please complete all sections carefully and provide accurate information. Submission of this form does not automatically guarantee approval or funding. All requests are subject to verification, review and approval by the Foundation's authorised team.

Privacy Notice: Only approved photographs, patient story and verified campaign information will be displayed publicly. Private documents, identity numbers and medical records will never be published.

Patient Information

Patient full name

Patient date of birth

Day

Month

Year

Gender

Contact mobile number

Contact email address

City / Town

District

State

PIN code

Patient approved photograph

Upload a patient-approved photograph. Accepted formats: JPG, PNG.

Upload a clear, patient-approved photograph. This photograph may be displayed publicly on the campaign page. Accepted formats: JPG, PNG.

Medical Details

Diagnosis / Medical condition

Treating hospital / Medical centre

Hospital city / Location

Treating doctor / Specialist

Treatment description

Verified treatment cost (₹)

Enter the total verified treatment cost as per the hospital estimate. This amount will be displayed as the fundraising target on the campaign page.

Campaign deadline

Enter the date by which the funds are required for the treatment to proceed.

Hospital treatment estimate / Cost document

Upload the official hospital treatment estimate. Accepted formats: PDF, JPG, PNG.

Upload the official hospital-issued treatment estimate or cost document. Accepted formats: PDF, JPG, PNG. This document will be used for internal verification only and will not be published publicly.

Medical reports / Doctor's letter

Upload relevant medical reports or doctor's letter. Accepted formats: PDF, JPG, PNG.

Upload relevant medical reports, prescriptions or doctor's referral letter. Accepted formats: PDF, JPG, PNG. Up to 3 files. These documents are for internal verification only and will not be published publicly.

Applicant / Guardian Details

Please provide details of the person submitting this request. This may be the patient, a family member or an authorised representative.

Applicant full name

Relationship to patient

Applicant mobile number

Applicant email address

Applicant city / Town

Applicant state

Patient Story

Please provide the approved patient story and background information. Only information approved by the patient or their authorised guardian will be published on the campaign page.

Patient story

How will this treatment change the patient's life?

Campaign name / Title

Verification Documents

Privacy Notice: All documents uploaded here are used solely for internal verification purposes. Documents such as Aadhaar, income certificates, medical reports and private financial documents will never be published publicly. Only approved photographs, patient story and verified campaign information will appear on the public campaign page.

Identity document (patient or guardian)

Accepted formats: PDF, JPG, PNG. E.g. PAN Card, Voter ID, Passport. Do not upload Aadhaar number or full Aadhaar card.

Upload a valid government-issued photo identity document of the patient or authorised guardian. Accepted formats: PDF, JPG, PNG. For internal verification only — will not be published publicly.

Address proof

Accepted formats: PDF, JPG, PNG. E.g. Utility bill, Bank statement.

Upload a valid address proof document. Accepted formats: PDF, JPG, PNG. For internal verification only — will not be published publicly.

Additional supporting document

Accepted formats: PDF, JPG, PNG, DOC, DOCX. Upload any other document relevant to this request.

Upload any additional document relevant to this medical assistance request. Accepted formats: PDF, JPG, PNG, DOC, DOCX. Up to 2 files. For internal verification only.

Declaration & Consent

Please read each declaration carefully and confirm your agreement before submitting this request.

I confirm that the information provided in this request is true and accurate to the best of my knowledge.

I confirm that the patient has approved the use of their photograph, story and verified campaign information for the purpose of this fundraising campaign.

I understand that submission of this request does not automatically guarantee approval, campaign listing or funding. All requests are subject to verification, review and approval by the Foundation's authorised team.

I understand that private documents including identity numbers, medical reports, prescriptions and financial documents will not be published publicly and will be used solely for internal verification purposes.

I consent to the processing of the personal information provided in this form for the purpose of medical assistance campaign verification and administration in accordance with the Privacy Policy of ADIYOGI JNANA FOUNDATION.

I agree to the applicable Terms and Privacy Policy of ADIYOGI JNANA FOUNDATION.

Applicant Declaration