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Name

Age

Married or unmarried

Childrens

Profession

Email

Residential Address

Mobile or Land Phone

Medicine required for which disease?

Any other diseases you have state it or type NIL

Duration you had the disease for?

Had any surgery? Undergoing Allopathic/Ayurvedic/Siddha/Homeo/Holistic treatments. State details?

Which part of body you have problems? Symptoms you have? State details.

Approximate Date of visit to our center

Whether the medicine will be collected Direct at our center or have to be send by courier, parcel service, etc.

Any additional details of disease or body condition, you like to state

Declaration:

I herby declare that I am willing to undergo the Ayurvedic/ Siddha treatments and do consultation for my diseases and is ordering

Medicines for my above stated diseases, and agree to follow the veg diet or any adviced foods, refrain from smoking, intoxication, and unadviced foods, bakery items and I shall be solely responsible for breaking the do's or don'ts. The organization will not be liable for any carelessness or any consequences for the medicines taken by me. I and my friends or relatives shall not in any way have any claims or ask for any compensations for any problems that may arise from the process of treatmwents. click Agree checkbox below, if you agree..

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