Online Consultation Form

I am sending online consultation to knowing about the various Retreat programmes, ayurvedic treatments, and wellness therapies available at Svaztha Ayurveda Wellness & Retreat. To register for our online consultation, please fill the form given below and send us all the details of your health problems, with a full history of treatments received so far.

Date:
pick Date
Name*
Nationality
Date Of Birth*
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Height (cm):*
Weight (Kg):*
Sex:*
Occupation:*
Address:
* * * * * *
E-mail address:*
Landline #:
Mobile #:*
Skype/Facebook:
Are you a Vegetarian?
Matiral Status:*



Does your complaints aggravate during (please tick):




Past Medical History:
Family Medical History:
Surgical History:
Allergies to any medicine or food:

Present complaint with duration(most serious problem first):
If already diagnosed - details:
Upload related documents of already diagnosed and investigated details:


Do you have any of the following ailments:

Upload related documents:

Most recent tests done:












Upload related document(s):

Details of children:

For Females* (Menstrual Cycle):