Patient Information Form (Online)
Welcome to Witness Self. - Homoeopathic Consultations with Dr. Rina Dedhiya BHMS, MD.

One needs to look into intricate details of a person from a Homoeopathic perspective, which involves exploring the physical, emotional, subconscious and other areas of a persons life.  Witness Self is a free flowing safe space which allows you to observe yourself without conclusions and judgments. This brings about a holistic understanding of an individual and helps the Homeopath to find the best possible Homeopathic remedy.

Lets meet and embark on this healing journey! Please fill in the form below for ease of consultation.
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Email *
Full Name *
Age *
Sex *
Address (please write your courier address with pincode) *
Phone Number (preferably Whatsapp Number) *
Medical History (like HTN/DM or any other) *
Complaints for which you are seeking consultation. List 4-5 main complaints in short *
Are you on regular Allopathic/Ayurvedic/Herbal Medication? (Please write the names below and since how long have you been taking the medicines) *
Have you taken Homoeopathy before? *
Preferred day and time for first consultation which is 2hours PLEASE SELECT TIME AND DAY OPTIONS BOTH *
Please select all that apply
Follow up preferences (Follow ups are once a month and take 20-30 mins)
Please select all that apply
10.30am - 1.30pm
5pm to 8.30pm
Monday
Thursday
Saturday
Clear selection
Allergies to any medication or food? *
Any other significant points to note? *
I give consent to record the consultation sessions. (These are for record keeping purposes only, if the information is used for future research then a separate consent will be asked for at that time) *
I would love to receive newsletters/articles/workshop information. (Related to Health and Wellness) *
Required
Type of Payment. Package information will be sent to you via email/whatsapp if you opt for it. *
Required
Mode of Payment *
Who were you referred by? (Name) *
PLEASE EMAIL YOUR LATEST AND IMPORTANT REPORTS BEFORE THE FIRST SESSION. EMAIL ID rinadedhiya@gmail.com. NO REPORTS WILL BE RECEIVED ON WHATSAPP UNLESS MENTIONED

A 50% payment in advance is mandatory to confirm your appointment (Remaining amount can be paid after consultation)
Witness Self Homoeopathic Healing
Thank you for expressing interest and sharing your information, I will get back to you in 2-3 working days if appointment hasn't been scheduled already. Warm regards Dr. Rina Dedhiya BHMS, MD (Hom)
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