Consultation Request Form

Telemedicine Consultation Form

  • Use this form only if you are contacting us for the first time.
  • If you are an existing patient and are having any queries, please contact us through email or phone.
  • Fields marked with an asterix (*) are mandatory

Name of the Patient:*
Date of Birth (dd/mm/yyyy):
Age of the patient:*

Sex:* Male Female

Current Address (with country and postcode): *

Street Address 1: *

Street Address 2:

City/ Town: *

Pin/Post/Zip Code: *

State: *

Country: *

Contact Numbers (with country and area codes) and Email Address:

Mobile: *

Home Phone:

Work Phone:

Email Address:*

Choose Your Consultation Package:

Please Select Your Country First From The List Above

Critical Diseases:
Renal Failure, Heart Diseases, Brain & Spine Diseases, Ulcerative Collitis, Crohn's Disease, Cirrhosis of Liver, Infertility, Diabetes, Rheumatoid Arthritis, Female Diseases (Endometriosis, Ovarian Cysts, Uterine Fibroid), rare diseases like genetic diseases and birth defects. If a condition can not be easily defined, our Medical Team will decide under which category the case will fall after going through the details of the case.

Description of your Symptoms: *

  • Please enter a description of your symptoms in the box below, as detailed as you know.
  • (Don't worry if you don't have too many details - this gives us a starting point. When we discuss the symptoms with you it will be by phone or email, or video if you have chosen this option.)

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