Maharshi Ayu Clinic,Ayurvedic Clinic,Ayurvedic Vaidya,Nadi Vaidya,Ayurvedic Consultant,Ayurvedic Physician

Kindly fillup the required information
(*) Fields are Mandatory

Name :

Date of Case :

Address:

Patient's Profession :

Phone :

Status :

Fax :

Reference Obtained From:

E-Mail :

Your Body's Nature:

Age :

Name of Operations done :

Diagnosis & Main Complains:

Sleeping Status :

Hunger & Relish:

Diet :

Constipation or Stool Status:

Diet choices :

Habits:

Urine Report & timings - colour etc. :

Blood Pressure Data :

Weight :

Height:

Structure of Body :

Semen Report:

M.C. Condition :

Childrens:

Abortion or Miscarriage History, if any :

Last Children's Age:

Hemoglobin (H.B.) :

Diabetes Data

Blood :
Urine :

Any Special Hint :

Convenient Diet or things:

Inconvenient Diet or things:

You can send our consulting fee or medicine, parcel, bill's, money in advance by crediting it in any SBI BANK (which have core systems facility) in favour of our SBI (SB) A/c No. 10397316778. Kindly also send your latest Laboratory or other reports by email consult@ayurvedicclinic.co.in after submitting this form.

Address: 22, Moonlight Complex, Opp. Gurukul, Drive-in-Road, Ahmedabad 380052 (Guj.) India
Phone: (Cl.) ++91-79-27490762 (Res.) 26855687 Mobile: ++91-9427001460 E-mail: consult@ayurvedicclinic.co.in