MODERN NATUROPATHY                                  
Santosh Ambekar (B,Sc, N.D (Diploma in Naturopathy)
(Certified Naturopath / प्राकृतिक चिकित्सक/ A Drug Free Treatment)
149/4526, Vikhroli, Mumbai, Maharashtra, Pin-400083. Whatsapp No.8692924558
Website: www.Easy2shopOnline.com/ModernNaturopathy
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Wellness Client / Patient Information Form
(For Appointment & Further Details, Please Whatsapp@8692924558 After Submitting This Form)
Naturopathy Consultation Details ( Immunity Kit ( Nasya Drop & Herbal Tea) , Protein Powder or any Health Product  Name, Treatment Name Like Liver cleanse,  Online Naturopathy Consultation, Essential Health Education Program, Juice Therapy, Desi Cow Ghee or Any other Natural Product Name, Write if any other things.) *
Full Name *
Gender *
Age (Years) *
Weight (kg) *
Height (Feet) *
Waist (Inches) *
Belly/tummy/Stomach Size (Inches) *
Marital Status *
Name Of Parent or Spouse
Address *
Mobile No (Whatsapp No.) *
Problem Description *
Problem Duration *
Past Surgery Details *
Past Medication Details *
Current Medication Details *
Recent Blood Test Report Highlights *
Allergy if Any *
Food Habbit *
Addiction if any (alcohol, smoking, tobacco, gutkha etc) *
Occupation *
Working Hours & Shift Details *
Fees & Payment Details ( Please pay to Santosh Govind Ambekar, Saving Bank Account Number 22511118786, IFSC CODE : SCBL0036046, Standard Charted Bank, 23-25, MG Road, Mumbai or Pay at Google Pay Tez account Mobile Number 9892005972 to Santosh Ambekar *
Required
Payment / Fees in Rupees / Receipt No. / Reference No. *
I understood the terms and conditions as explained by Naturopathy Practitioner so that I paid consultation fees and other charges if any. I knew that these charges & fees are not returnable in any condition as Naturopathy consultation is based on Health Education and Self Treatment after self study on self responsibility by using food as Medicine as Naturopathy is drug free lifestyle based treatment. *
Required
Name of Client/Patient Who agreed with above Terms & Conditions. *
Date *
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