Dr. Priyabrata Adhikari

Pro Bono Application

Dr. Adhikari offers pro bono surgical services to a limited number of patients per month who are financially unable to afford treatment. Please fill out this application form to be considered.

Patient Name *

Age *

Contact Number *

Email Address

Address *

Medical Condition / Diagnosis *

Required Surgery / Treatment *

Annual Family Income *

Financial Hardship Details *

Supporting Documents

📄 Click to select files
Upload income certificate, medical reports, etc.