Appointment Form
*
Case Type:
New Case
Follow Up
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Appointment Type:
INPERSON
ONLINE
CHILD CENTRIC
*
Patient Type:
National
International
*
First Name:
Mr.
Dr.
Mrs.
Ms.
Miss.
*
Last Name:
*
Gender:
Male
Female
*
Date of Birth:
*
Age:
*
Choose Date of consultation:
*
Location and Postal address:
City
State
Country
Pincode
*
Contact No:
-- Country Code --
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81
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84
86
90
91
92
93
94
95
98
211
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216
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370
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375
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382
385
386
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389
420
421
423
500
501
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591
592
593
594
595
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599
670
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692
850
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886
960
961
962
963
964
965
966
967
968
970
971
972
973
974
975
976
977
992
994
995
996
998
1242
1246
1264
1268
1284
1340
1345
1441
1473
1649
1664
1670
1671
1684
1758
1767
1784
1787
1809
1868
1869
1876
7370
*
WhatsApp No:
-- Country Code --
0
1
7
20
27
30
31
32
33
34
36
39
40
41
43
44
45
46
47
48
49
51
52
53
54
55
56
57
58
60
61
62
63
64
65
66
70
81
82
84
86
90
91
92
93
94
95
98
211
212
213
216
218
220
221
222
223
224
225
226
227
228
229
230
231
232
233
234
235
236
237
238
239
240
241
242
243
244
245
246
248
249
250
251
252
253
254
255
256
257
258
260
261
262
263
264
265
266
267
268
269
290
291
297
298
299
350
351
352
353
354
355
356
357
358
359
370
371
372
373
374
375
376
377
378
380
381
382
385
386
387
389
420
421
423
500
501
502
503
504
505
506
507
508
509
590
591
592
593
594
595
596
597
598
599
670
672
673
674
675
676
677
678
679
680
681
682
683
684
686
687
688
689
690
691
692
850
852
853
855
856
880
886
960
961
962
963
964
965
966
967
968
970
971
972
973
974
975
976
977
992
994
995
996
998
1242
1246
1264
1268
1284
1340
1345
1441
1473
1649
1664
1670
1671
1684
1758
1767
1784
1787
1809
1868
1869
1876
7370
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:
*
Day Of Appointment Preferred:
Wednesday
Friday
*
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
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Swasthya Homoeopathic Healing!