Online Consultation Form

I am sending online consultation to knowing about the various Retreat programmes, ayurvedic treatments, and wellness therapies available at Svaztha Ayurveda Wellness & Retreat. To register for our online consultation, please fill the form given below and send us all the details of your health problems, with a full history of treatments received so far.

pick Date
Date Of Birth*
Height (cm):*
Weight (Kg):*
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E-mail address:*
Landline #:
Mobile #:*
Are you a Vegetarian?
Matiral Status:*

Does your complaints aggravate during (please tick):

Past Medical History:
Family Medical History:
Surgical History:
Allergies to any medicine or food:

Present complaint with duration(most serious problem first):
If already diagnosed - details:
Upload related documents of already diagnosed and investigated details:

Do you have any of the following ailments:

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Most recent tests done:

Upload related document(s):

Details of children:

For Females* (Menstrual Cycle):