Patient Registration Form

Patient Name : Dr. Mr. Miss. Mrs.
 
Date of Birth *
Address : *
Phone No. (Resi.)
  (Office)
Mobile No.
Email : *
Age : *
Sex
Marital Status
Problem *
Since When *
Reason *
Allergies (if Any)
A Brief History
Questions about life style (More emphasis on thoughts)
Medical Confirmations
Doctor's Name
Dr. Contact No.
Description of Doctor's Diagnosis
Medication
Registration for *  Acute Chronic patient  
on as a
 
Enclosed Herewith Rs.*
By
Cheque No.
 
Dated:
Drawn on
as
Balance Amt. of Rs.*
will be sent by Date*
 
Terms & Conditions :*
I Agree to the Terms & Conditions stated above.
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Reiki Effects

5 Principals of Reiki