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consultation-Form

Name:
Age:
Sex:
Marital Status:
Height:
Weight:
Occupation:
Mail-id:
Phone No:
Address:
Discuss Your Problem:
Treatment:
Duration & Price:
30 Days (Rs.1000 or USD 25)
60 Days (Rs.1800 or USD 45)
Do you consume alcohol/tobacco in any form?:

Do you have any of these medical problems?   High BP/Diabetes/Thyroid Dysfunction/Prostate:                                         Enlargement/Cancer/Allergies 

What types of treatment and medicine have you taken so far?:
What have been the results?:
Do you have any investigation report  regarding  your disease:
How is your appetite and digestion:
How often do you have constipation:
Do you sleep soundly:
Details of your home climate:
Are there any other detail you would like to share:
How did you hear about us?: