ONLINE TREATEMENT

TREATMENT CONSULTION FORM

Submit this form only in case of first-time treatment.

Please gather and scan copies of your payment receipts, medical records, and test reports before filling out this form.

Please contact with us over phone or through e-mail in case of an old patient Having any queries.

**Fields marked with an asterixis (*) are mandatory.**

Personal details of Patient

First Name *Write your first name

Last Name *Write your last name

Date

Write your date of birth

Age of the patient *Write your age in number.

Sex of the patient *MaleFemale

Occupation of the patient *

Name of the life partner *

Age of the life partner *Write your age in number.

Occupation of the life partner *

How many years have you been married? *Enter the correct value of the years.

How many years have you been treated before but no child is born *Enter the correct value of the years.

Phone *

Phone 2If previous number is not all time available

Email Address

Wright your present address

Street, Village Address *

Apartment, suite, post etc

City *

State/Province *

ZIP / Postal Code *

Country *

Please select this option if the delivery address for sending your medicine is different from your current address. *Yes it is different addressNo it is same address

Street, Village Address *

Apartment, suite, post etc

City *

State/Province *

ZIP / Postal Code *

Country *

What is the nature of menstruation?

How regular are your menstrual cycles? *Menstrual Cycle Regularity

How many days does your menstrual bleeding last? *Duration of Menstrual Flow

How many days does your menstrual cycle typically last ? *Cycle Length (from the start of one period to the start of the next)

How would you describe your menstrual flow? *Flow Characteristics

What kind of shape do you have on your periods? *

Do you experience menstrual cramp (dysmenorrhea)? *Pain and Discomfort

Do you experience pain in other areas? *Pain and Discomfort on back, thighs, brest etc

Menses Sensation? *Pain and Discomfort time

Do you have any symptoms before your period starts (PMS)? *Premenstrual Symptoms

If yes, what symptoms do you experience? *BloatingBreast tendernessMood swingsFatigueSelect all if that applicable.

Do you experience any other symptoms during your menstrual cycle? *NauseaDiarrheaHeadachesOtherSelect all if that applicable.

At what age did you have your first period (menarche)? *Age and Menstrual History

Patient Problems

Thyroid *

TSH level *Enter the correct value specified in the report.

Thyroid test file upload *

Please upload up to 5 files, in order from oldest to newest.

Cyst: *

Size of cyst *Enter the correct value specified in the report.

Cyst test file upload *

Please upload up to 5 files, in order from oldest to newest.

Abortion: *

Number of occurrences *Enter the correct value specified in the report.

Gestational age at time of abortion (weeks) *Enter the correct value specified in the report.

Tumour: *

Size of tumour *Enter the correct value specified in the report.

Stage of tumour *Enter the correct value specified in the report.

Tumour test file upload *

Please upload up to 5 files, in order from oldest to newest.

Endometritis: *

Endometrial thickness *Enter the correct value specified in the report.

Presence of inflammatory cells: *

Endometritis test file upload *

Please upload up to 5 files, in order from oldest to newest.

Tumours in Ovary: *

Size of tumour *Enter the correct value specified in the report.

Stage of tumour *Enter the correct value specified in the report.

Tumours in Ovary test file upload *

Please upload up to 5 files, in order from oldest to newest.

Fallopian Tube Blockage: *

Affected tube: *

Degree of blockage *Enter the correct value specified in the report.

Fallopian Tube Blockage test file upload *

Please upload up to 5 files, in order from oldest to newest.

Salpingo-Oophoritis: *

Affected areas: *

Severity : *

Salpingitis/Oophoritis test file upload *

Please upload up to 5 files, in order from oldest to newest.

Tuberculosis (T.B.): *

Type of T.B.: *

Tuberculosis (T.B.) test file upload *

Please upload up to 5 files, in order from oldest to newest.

Patient Past disease history

Tuberculosis (T.B.): *

Thyroid *

Measles: *

Jaundice: *

Mumps: *

Skin disease: *

Write skin disease type *Enter the correct value specified in the report.

Threatened abortion: *

Habitual abortion: *

Surgery if any: *

Write the surgery type & name *Enter the correct value specified in the report.

Family disease history

Syphilis *

Gonorrhoea *

Cancer *

Diabetes *

Overian cyst *

Fibroid in uterus *

Tumour *

Tuberculosis (T.B.) *

Patient Present Symptoms

Thirst *

Appetite *

Body Type *

Time of Symptom Onset *

Literalities *

Feel Better In *

Urine *

MessagePlease share any additional information you think we should know.

Consultation Fees:

INR

Please mention your consultation booking fee here which is minimum Rs.500.

Upload Payment Prove *

No file chosen

PAYMENT

Package Rate Rs- 50,000/- For up to 18 Months
( Medicine + Consultation Fees )

Package Rate $750 USD For up to 18 Months
( Medicine + Consultation Fees )

Please Deposit Cash in our State Bank Of India

Bank Name : State Bank Of India
Account Holder Name : Paritosh Kumar Biswas
Account No : 31940269393
A/c Type : Savings
IFSC Code : SBIN0005367
BRANCH : BELGACHIA DUTTA BAGAN MILK CLY,
64/1/46A , BELGACHIA ROAD

ONLINE TREATEMENT

TREATMENT CONSULTION FORM

Submit this form only in case of first-time treatment.

Please gather and scan copies of your payment receipts, medical records, and test reports before filling out this form.

Please contact with us over phone or through e-mail in case of an old patient Having any queries.

Fields marked with an asterixis (*) are mandatory.

Personal details of Patient

Wright your present address

What is the nature of menstruation?

Patient Problems

Patient Past disease history

Family disease history

Patient Present Symptoms

PAYMENT

Package Rate Rs- 50,000/- For up to 18 Months( Medicine + Consultation Fees )

Package Rate $750 USD For up to 18 Months( Medicine + Consultation Fees )

Please Deposit Cash in our State Bank Of India

Bank Name : State Bank Of IndiaAccount Holder Name : Paritosh Kumar BiswasAccount No : 31940269393A/c Type : SavingsIFSC Code : SBIN0005367BRANCH : BELGACHIA DUTTA BAGAN MILK CLY, 64/1/46A , BELGACHIA ROAD

**Fields marked with an asterixis (*) are mandatory.**

Package Rate Rs- 50,000/- For up to 18 Months
( Medicine + Consultation Fees )

Package Rate $750 USD For up to 18 Months
( Medicine + Consultation Fees )

Bank Name : State Bank Of India
Account Holder Name : Paritosh Kumar Biswas
Account No : 31940269393
A/c Type : Savings
IFSC Code : SBIN0005367
BRANCH : BELGACHIA DUTTA BAGAN MILK CLY,
64/1/46A , BELGACHIA ROAD