Ayurvedic Herbal Clinic Ltd.

. Client's Name *

. Address

. Telephone

. Mobile

. E-mail *

. Present Problems:

. Past Health History:

. Family Health History:

. Present Treatment from Dr.:

. Blood Pressure:

. Food Intake History:

. Blood Test Reports:

. Any Allergy:

. Your Family Dr.'s Opinion about your Problems?

. How would you like us to respond?

E-mail

Fax

Phone

Post

Ayurvedic herbal clinic LTD does not make any unrealistic medicinal claims on any products or services. No refund for unused remedies. Never claim any money back or compensation from clinic or Therapist.

Thank You.

EMAIL :

*PRESENT PROBLEMS:

*PAST HEALTH HISTORY:

*FAMILY HEALTH HISTORY:

*PRESENT TREATMENT FROM DR.

* BLOOD PRESSURE:

* FOOD INTAKE HISTORY:

*BLOOD TEST REPORT:

*ANY ALLERGY? :

*YOUR FAMILY DR.'S OPINION ABOUT YOUR PROBLEMS?

*Ayurvedic herbal clinic LTD does not make any unrealistic medicinal claims on any products or services.No refund for unused remedies.Never claim any money back or compensation from clinic or Therapist.