Homeopathic Treatment consultation

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Paid Consultation Form:

Please provide us your complete desease details:

After the consultation form is filled by you, we would decide which medicines will suit you & further treatment plan is discussed mutually which includes - medicines to be taken, duration involved, diet and schedule to be followed. If you have any queries please feel free to contact us.

Kindly mention about your complaints in your own words. Please describe the trouble completely, including its origin, subsequent development and effects of treatments that were received.

We provide only Paid Consultation. Please fill the form if you are seriously looking for treatment - Casual enquiries will be deleted.

Fields marked with * are mandatory.

Name*
Age*
Sex*
Marital Status*
Telephone Number*
Email*
Full Address*
Occupation (Nature of Work)*
Present Complaints*
Area of body affected and when*
Sensations and pains experienced*
Circumstances (physical & emotional that have brought on the trouble)*
Conditions that increase the trouble*
Conditions that reduce the trouble*
All other accompanying troubles*
Personal History/Information
 
How much thirst you have*
What kind of food or drink you like most*
Your Habits >> How Much?*
 
Smoking*
Alcohol*
Tea & Coffee*
Sleeping Pills*
If you have an external problem please attach a picture ('.jpg','.gif','.bmp','.png' upto 0.5 MB)
   

 

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