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Online Consultation Form
Please fill in all required information. A fee of
₹500
is applicable.
Full Name *
Age *
Gender *
Male
Female
Other
Mobile Number *
Email *
Main Symptoms / Complaints *
Duration of Symptoms *
Do you have any Known Diseases? (Diabetes, BP, Thyroid, Asthma, etc.)
Current Medications
Any Allergies?
Preferred Consultation Day *
Tuesday
Thursday
Saturday
Preferred Time *
Upload Medical Reports (PDF / JPG / PNG) – Optional
Submit & Proceed to Payment
