Online Consultation Form

Please use the form below to describe your illness and click the submit button once. You will receive a reply within the next 24 hours and depending on the case you may be asked to provide more details. Please note that telephone consultation will be provided only to the existing regular patients who initially contacted us via the online form below.
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For details of Consultation charges click here. For details of payment mode click here.
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Personal Details (all fields marked * are mandatory)
Title:*          Mr. Mrs. Ms.  Mst. Baby
First Name:*
Last Name:*
Age:*             Years, Months
Sex:*            M F
Occupation:*

Postal Address
House/Building/Post Box No:*  
Street:                                        
Area/District:                            
County/State:*                          
Country:*                                  
Pin/Zip:                                      
Phone (including country and area code)
Residence:*              
Mobile:                      
E-Mail:*                   

Disease description
Main complaints* (Write down the major problems you face now like head ache/sneezing fits/sexual weakness/allergy etc. If there are more than one problem give numbers as 1. 2. etc giving the oldest problem first. Please describe the problem in plain English, do not use medical language)

Details of the complaints* (Give some details about each of the above as regards when did they start, how and when they increase or decrease etc.).

Medical/Drug history* (Give details of all the medications you had for these complaints including past and present medications)

Allergies/Hypersensitivities* (Give details of any known allergy/hypersensitivity you have to any drugs, foods or other substances.)

Payment details (Please click here for details)
Amount Paid*                                 €/AED/Rs
Payment mode*                                               DD, MO, Account Debit (payment/transfer), Online Payment, Western Union.
Name of Bank/Post office/Transfer agency* 
Date of remittance/transfer (mm/dd/yyyy).*     

Send to the department:*                                

I agree to the terms&conditions of the clinic* (Please tick the box)