Registration form
General instructions for filling up the online forms
In order to fill up the form online you shall make the preparatory arrangement as follows:
List out your area of concern\ sufferings in word form and save it.( 1000 words)

Write down the history of your sufferings starting it from the day, you had noticed the first symptoms and save it in word format (1000 words)

Arrange all your prescriptions\test reports in serials from starting treatment to till date in pdf form and save it.


What was the outcome of your one by one treatment in word format and save it.

Present status of sufferings\ symptoms with severity and frequency in word format.


Video clip of maximum 5 min illustrating all your symptoms severity and frequency.

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Email *
1. Full Name
2. Date of birth
MM
/
DD
/
YYYY
3. Mailing address
4. Contact no.
5. Whatsapp no.
6. Email ID
7. Primary Concern: List out of your area of sufferings
Submit
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