Patient Registration
INSTRUCTIONS [ * ]

Please Fill Up All The Details And Particularly Symptoms In Details,

Attach All Medical Documents By Scan Copy And Not Mobile Photo

Attach Pictures Of Affected Area ( If Suffering From Skin Disease )

Name* :
Age :
Sex :
Weight:
Job/Occupation:
Nationality:
Address :
Phone No :
Email Address* :
Food habits :
Present medical condition :
( Symptoms in detail / please eleborate your detailed symptoms )
Family History :
Past History :
Acidity/HeartBurn Headache or Gas if meals are delayed or skipped?
Gas Any Skin Infection/Dryness or Itching
Blood Pressure Pain or cramps in calf or soles of feet
Migraine/Headache Sugar or Diabetec
Constipation Blood Pressure
Current medications :
MRI or Scan reports :
Security Code* :

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Alopecia ( Hairfall )

Hi, My daughter Moksha suddenly started losing hair in a big spots in scalp area. We were very scared. We got reference of Dr Ravi Paneri

Weight Loss

I have lost nearly 11 kgs of weight and still reducing. Thank you.