APPOINTMENT FORM - SWASTHYA

BASIC INFORMATION FORM

Select clinic

Select

First Name

Last Name

Date of Birth

Gender

Location and Postal address

Contact number

Email id

Skype id

Complaints/diagnosis

Reports and images

Occupation

Reference

Language preferred

Translator details

Homeopathic Pharmacy/ Homoeopath details

Family physician/ consultant details

DAY OF APPOINTMENT PREFERRED

CONSENT FORM - The Video recording becomes an essential part for the assessment on our behalf. Swasthya Homeopathic Healing puts the confidentiality and security of clients and partners at a high priority And we would like to have your consent for the same as below. I understand that my case interview maybe recorded on video for the purpose of future reference, study and teaching.And the video will be highly kept anonymous with masking and voice alteration. Hence I give my consent for the same.

Any other Queries ?