Patient Declaration Comments or questions are welcome. * indicates required field First Name:* Last Name:* Age in years* Telephone* Email:* Address* Message: Diabetes (How Many Years) High Blood Pressure(Hypertension) (How Many Years) Heart Disease (How Many Years & details of treatment Recieved) Asthma Tuberculosis History of Stroke or paralysis History of epilepsy History of Psychiatric illness History of any admission in hospital/operation/Blood transfusion...Please give details if any History of smoking/tobacco chewing any time in your life Family history of Diabetes/High Blood Pressure/Heart disease...Please give details Medicines being Taken at present, please give details I confirm that I have understood that there is no guarantee given that the doctor will be able to understand my problem during the telemedicine consultation or that a prescription will be given. I also understand that no refund of fees paid will be done.* I confirm that the above given information is true to the best of my knowledge and belief and I give my consent for the terms and conditions specified above.*
