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Wellness Pro-forma

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Questions marked with a * are required Exit Survey
 
 

Wellness Pro-forma
 
 
 
* Name of the Bank/Corporate/Society
   
 
 
 
* Complete Address of Event
   
 
 
 
Type of Event
 
Basic Health Camp
 
Health Talk/Seminar/Work shop
 
Other
 
 
 
 
* Test Parameters/Topic to be conducted
   
 
 
 
Other Details :
 
 
 
Date and Time
DayMonthYearHrs.Mins.AM/PM
    
 
 
Bajaj SPOC (Coordinator Details)
First Name : 
Last Name : 
Phone : 
 
 
Corporate SPOC (Coordinator Details)
First Name : 
Last Name : 
Phone : 
 
 
 
Payment Details
 
Complimentary
 
If Paid, specify the payer
 
 
HAT - Networks - Health Administration Team -Bajaj Allianz General Insurance Company Ltd.,Second Floor, Bajaj Finserv Building, Behind Weikfield IT Park, Off Nagar Road,Viman Nagar,Pune - 411 014. (Maharashtra)Landline: 020 - 30512247/30512312 Fax No: 020 – 30475701 Regd. & Head Office: GE Plaza, Airport Road, Yerwada, Pune 411006. Tel (+91 20) 66026666 Fax (+91 20) 66026667