Appointment Form
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Case Type:
New Case
Follow Up
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Appointment Type:
INPERSON
ONLINE
CHILD CENTRIC
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Patient Type:
National
International
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First Name:
Mr.
Dr.
Mrs.
Ms.
Miss.
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Last Name:
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Gender:
Male
Female
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Date of Birth:
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Age:
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Choose Date of consultation:
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Location and Postal address:
City
State
Country
Pincode
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Contact Number:
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Contact Email:
Skype Id:
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Complaints/diagnosis:
Reports and images:
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Occupation:
Reference:
Language preferred:
Translator details:
Homeopathic Pharmacy/ Homoeopath details:
Family physician/ consultant details:
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Day Of Appointment Preferred:
Wednesday
Friday
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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 ?
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Swasthya Homoeopathic Healing!
