Dr. P. Banerji's Homeopathic Healthcare

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/yy):

Age of the patient:*

Sex:* Male Female

Current Address (with country and postcode): *

Delivery Address for Sending Medicines (if different from above):

Same as above

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

Mobile:

Home Phone: *

Work Phone:

Email Address:*

Choose Your Consultation Package:

One Time Consultation
(INR 1000 / $ 45 USD / £ 32 GBP / €35 EUR)

Six months unlimited consultation for Non Critical diseases
(INR 3500 / US$ 175 / £ 120 GBP / €127 EUR )

Six months unlimited Consultation for Critical diseases
(INR 5500 / US$ 250 / £ 170 GBP/ €180 EUR )

One year Unlimited Consultation for Non-Critical Diseases
(INR 7000/ US$ 300 / £ 204 GBP / €216 EUR)

One year Unlimited Consultation for Critical Diseases
(INR 9850 / US$ 450 / £ 306 GBP / €324 EUR)

Critical Diseases:

Cancers, Brain Tumours, Renal Failure, Heart Diseases, Brain & Spine Diseases, Cirrhosis of Liver, Infertility

Description of your Symptoms: *

Please enter a detailed description of your symptoms in the box below.

If we need more information we will contact you either on phone or email.

How did you hear about us?

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