< .

SirH. N.RelianceFou;ndation Hospital

. ..

And Researc~ Centr~

Date: 3rdDecember 2016To,

Whomsoever it may concern,

This is to certify that Baby of Sandhya Mishra, 4 months old male child, S/O Shri. Ankit

Mishra, residing at Kandivali, Mumbai, Maharashtra, has been under our follow-up and is

having major congenital heart defect in the form of Tetralogy of Fallot (TOF). He requires

early repair of TOF in order to survive and lead a normal life. It is a Major cardiac procedure

';:.' carrying 97-98% success rate in the present circumstances.

The approximate cost of the procedure and the postoperative treatment for this

operation is around Rs 2,75,0001- for a maximum of 15 days of hospital stay including the

usage of prosthesis and blood and blood products.

The child's parents are young and have financial hurdles. Hence I would request you to

kindly help the parents in arranging the funds required for his procedure.

The DID should be drawn in favour of "Sir H.N.Hospital Trust" Payable at Mumbai.

The surgery should be done in the next few weeks for lasting benefit to the child.~~~----~~~~~Any queriesl clarifications in this regard are most welcome

Z I Dr. Shr e I Jain,MD, F ,Fellowship (SCH, Canada)Consultant Interventional Pediatric CardiologistCenter for Congenital Heart DiseasesT-107, First Floor, Tower BuildingSir H.N. Reliance Foundation HospitalPrarthana Samaj, Rajaram Mohan Roy RdMumbai-400004Landline- (022)-61305015/5000/5301; Mobile: +919167383837Ernail: Shreepal.jain@rfhospitai.org/shreepaI316@yahoo.co . in

Managed by Sir H. N. Hospital Trust

Prar thana Sarna), Raja Rarnmohan Roy Road, Girgaum, tvlumbai - 400004, Phone: 6130 SOOO

Name : Baby of 5andhya Patientld. : 10064037Date of Birth : Aug 1,2016 Age : 4 months Sex : MaleCase Type : Outpatient Case Case Number : 1000153064Attending Physician : 5hreepal Jain Visit Date : Dec 3, 2016

Clinical Notes

Chief Complaints4 month old male childReferred from Wadia Hospital.CHild is a diagnosed case of Tetralogy of Fallot.Child is presently admitted in Wadia Hospital for convulsion.No further episodes of seizures after admisision. .Has dysmorphic features.Child was diagnosed to have CHD at 15 days of age.FTNVD, Birth weight 3 kg approximately.Child was admitted in NICU for 20 days in view of respiratory distress.

ExaminationCHild was evaluated at Wadia HospitalEvidence of dysmorphic facies++Cyanosis+CV5: 51 normal, 52 single, 216 E5M+

Assessment

Echo done at Wadia hospital showed features of TOF.

Plan

Child has been advised workup for genetic association especially for 22q11 deletion syndrome.Have also asked for checking serum calcium levels in view of seizures.Child needs TOF correction surgery.Refer to charity cell for further financial assistance.

Print DatelTime : 03/1212016 / 5:30 PM

Dr. Shre a inPaedia ic CardiologistMed. Council No.2002l1213764MBB5,MD(Paed.), FNB(PaediatricCardiology),Fellowship (Canada)

Page 1 of 1

~·i;',Sldlq·'ii .. ' .: ','"

\3W -sra:~T'l1TJ# f.tcmft ~;;r ~ ~ '«iT ~ ~ s. ~rW~!ilJ;4)~1.~41~~'~.Pc ~.'.~u-..fl~i\il,~SHiIY"lit \3W "fc;;SlT ~ I~<f; ~ fl:hrr # ~?iTI ~if'i30oo··'if~I~1t~.Three Thousand ~I~ ~ ¥f ~ a:rp:.r~.36000 ;;r ~T~if~. Thirty Six Thousand ~1<Sw:r 9iT ~ tl '4 HI <?il €II~I ~ >fli1'1JT

'0f ~ ~ #~ B- m.,- .~.''€I9l ~ ·«~"H.I

~'lfI1T'lT~ ,,"l'fS:IR'f'~'~IITU~<lT'Cf't;<rPPlT~Q<TT~~~~~1 ~~if, ~~arownfilrqWfPro~1~'lfI1T'lT'ft~http:fk~districtup.nic.in'R~~~9Po fi'f,l::~9PO ~'M:,~mr;;rrWii<lT~

~ageft~if~ ~ ilHi41d mt.--.."--.,--·----------

Page 1 of 1

~.

~16430010202455435191025482

<:f".:rr ~fhr (~}l<r~<il@ f.'t"&1<fi$Iq IfiJ! €I f*<:rr 'jffifT ~ No:f-f/:rft"'4TcfT 9iT ;:n+rv,cpr;:f~

~. m'4'

.~

'.'''''cO- f'

.. /;.'ii~~:::.,i}~·:~>". j~'~,.,.. '

Digitally Signed by DINESHKUMAR MISHRA O--GOVT OFUP, OU="GOVT OF UP,C=IN,CN=DINESH KUMARMISHRA, S=Uttar Pradesh

RntC<i1~~,SjQlq'llii

"

Ittp:11l64.1 00. 181.28lepistrictiCertificate/INCOME!Forms/printincomeCel rt.aspxvapplication. 25/11/2016

~:25f11/2016

.:';S:;,£::lC-:- ,:;'[; {i!~id q:.;:1'3iz''2:jact 61f it t:&Tg-if.; ::'t2~' &T ~:~m\3{fu'i2.~ C I prij' 2016 if Rd{JGl

" ;;) - t,..,...:..~_..;:;.__ " _,~.i" _~_~ -, _" - - , - -e ..-.-Pc ~ -~~~: 11 c~. w-/ f~t (,.!~~6'! f?~t.i 2~T0'fon&f }:tIel (t:.1f~u 0:.r):(l :;1:.,: --51r8.T<:;~{:'Jr~, :c. .~.0 c mR fiS O~UT0 l!Q ~ (5.3.0 G 1fu fu'iJ'iTrO 'd~ ~it '({;:QRl ::;i~lC1~ Ri¢ctl rJ:;

,-:,,_,...,.,__ r-17 ~':.. ~•.••••_.... ~. • .~.~ ""~'r.::~ " ;....... -rl- ~-a.tit/~a1- 11 s;rr":1 QfZfi ~~ '~;V1G1i :;if'-itp ~ di <g4,<qOT ~~r:6~~\,!Cf «r~~Dlfcg C>:.!dL rp<?t -,R' ;jM Ci5f 4~ "?:illdf'<

<i1~~~1f~,tJfi ;"

59412511 0167

~mr.r~ __ ~1

U~ :http://fcs.up.nic-io

r.J4.>.~.~'JZ>_"""-~~~ ~~.~ .•.7.> ~z--~...:c;:-._..-~_4=_"-

i

II '@Rf cr<n n:r<f ~

-:;\1; >RliT l(mf'f

: 217340015654

: BHAVANI GAR.Y

:"-fi>r<ftmmmm:m~mm:~: 72. BHAWANiGARH. BHAVAII/\ GARH. GAURA. miT'f'lG-

230301,

"T~-":/,~;;o: 434419086393

"j,f.'3~H~;:;n:r

Nerr/'l1i'rUrlT'<i!:r>ft,~M'=t !-;;t 'q-i[ 111

im'.1Tf.'li~R';to:---

iffi~'f.T'lTI'f

o;;""~ .~~, '1f'lii u~ :4 (Four)

Digitally Signed, ByANIL KUMAR SONKAR

1CC856A2020029BO

~: 16-01-2016

AnllKumarS~rl wa~

~omt~~-".t~~~~~mRmIT Solution Provided B,(: NaIionallnfotmatics Cenlre(NICl. UP.

..