Your Name
Age
Marriage or Unmarried
How many Children?
Your profession
Residential Address
Phone (Landphone or Mobile Number - very essential for courier or cargo services)
Email
Which disease you are wanting medicine mainly for?
Any other disease or problems you have like BP/Cardiac/cholestrol/diabetic/Nil?
From how many years you have the disease?
Which part of the body you have problems? Previously had any surgery or Nothing? Give details
Symptoms of disease you feel normally
Whether taking Allopathic/Ayurveda/Homeopathy or any other medicines till now?
Give your approximate date of direct visit to us for treatments or consulting
Specify details whether you want the medicine to be send by courier/parcel service/cargo.
Any Additional Details of Disease you like to mention other than asked above.
My Declaration
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