APPOINTMENT - Swasthya Homoeopathic Healing!

*Case Type:

New Case Follow Up

*Appointment Type:

INPERSON ONLINE CHILD CENTRIC

*Patient Type:

National International

*First Name:

*Last Name:

*Gender:

Male Female

*Date of Birth:

*Age:

*Day Of Appointment Preferred:

Tuesday Thursday Saturday

*Day Of Appointment Preferred:

Wednesday Friday

*Location and Postal address:

City

State

Country

Pincode

*Timezone

*Contact No:

*WhatsApp No:

Same as Contact No

*Contact Email:

Skype Id:

*Complaints/diagnosis:

Reports and images:

*Occupation:

Reference:

Language preferred:

Translator details:

Homeopathic Pharmacy/ Homoeopath details:

Family physician/ consultant details:

*CONSENT FORM - The Video recording becomes an essential part for the assessment on our behalf. Swasthya Homeopathic Healing puts the confidentiality and security of clients and partners at a high priority And we would like to have your consent for the same as below. I understand that my case interview maybe recorded on video for the purpose of future reference, study and teaching.And the video will be highly kept anonymous with masking and voice alteration. Hence I give my consent for the same.

Yes No

Any other Queries ?

Appointment Form