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 (£12.00 / $24.00 / €18.00 / Rs. 1000/-)

Six Months Unlimited Consultation (£60.00 / $120.00 / €90.00 )

One Year Unlimited Consultation (£100.00 / $200.00 / €150.00 )

Six Months Unlimited India Package ( Rs. 3500/- )

One Year Unlimited India Package (Rs. 7000/-)

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.

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