General information

* Field are mandatory !

Name

Age

Gender	*		Male		Female

Add.

City

Tel.

Country

Alternative Tel.

E-mail

Alternative E-mail

Email Id is very important for future communication, please be careful while typing email id and make sure that you typed it correctly.

Description of your problem in your words

Attach the Pictures of only affected area. (File size should not more than 3 MB )

Choose a file...

Do you want to schedule Skype live consultation with Dr. Rohit Shah ? *Skip this if you are not interested.

Live Consultation Fees:

Yes. I am interested.

* Conferencing time will be given later. * Preferred languages English or Hindi.

Security Check Box ( * This is mandatory. This will help us to prevent automated registrations)

Notes

Registration is completely free. If your registration form is submitted successfully then you will get a confirmation message with patient idon your registered email address.If you do not receive your patient id then please submit your details again.
Patient id is necessary for any future communication,sending picture files, placing an order or follow up treatment.
After receiving your details , the team of our expert doctors will give their opinion within 3-7 days.
If you are not able to send online form click here to download the consultation form in MS Word format .
By submitting this form you are agreed to our terms and conditions.

Follow up Treatment

General information

* Field are mandatory !

Name

Age

Gender

Male

Female

Add.

City

Tel.

Country

Alternative Tel.

E-mail

Alternative E-mail

Email Id is very important for future communication, please be careful while typing email id and make sure that you typed it correctly.

Mention your Patient ID or name of the patient and select the branch where you registered first.

Patient Id or Name of the Patient:

Doctor & Branch Name:

(Select the support center or name of the doctor, where you registered first time.)

What changes did you notice after staring herbal treatment ? describe in your words.

Attach the latest picture of affected area after starting the treatment.

Choose a file...

5	Payment Details

Security Code ( * This is mandatory. This will help us to prevent automated registrations)

Notes

Treatment package is specially designed according to country weather.
Abroad Indian patients are requested not to apply for Indian products but apply for
the group of the country where they belong to.
Product will be send by Courier / Speed Post.
Online Tracking is only available if provided by Courier / Post / AirMail.
Approximate time to receive the products. For abroad patients 17-20 days ( depending upon the country).
Approximate time to receive the products. For Indian patients 7-10 days.
Product will be couriered after realization of Payment.