Medical Consultation Form
Please fill the form to get Medical Advice from our doctors.
Book An Appointment With Dr. Prashant Jain
Patient Name
*
Valid patient first name is required.
Valid patient last name is required.
Email
Phone Number
*
Age
*
Valid age is required.
Gender
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Male
Female
Other
Address
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Please enter your address.
Address 2
(Optional)
City
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State / Province
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Postal / Zip Code
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Health Check
Fill the Details
Heart Rate
Blood Pressure (in mmHg)
Height (in feet and inches) *
Weight (in kilograms) *
Blood sugar (in gm/dl)
Please explain why do you want a consultation?
*
History of past illness (if any)
*
Family History (Does any of your blood relation suffer from similar illness)
*
Drug History ( Do you use any drug, alcohol or tobacco habitually )
*
Do you have any experience of using cannabis in any form ? if yes please explain in which form and side effects if any
*
Rate your sleep on scale 1 to 5:1
*
Worst
1
2
3
4
Best
5
Please rate your sleep on scale is required.
Are you allergic to any drug, antibiotic or any other supplement?
*
Current Medication, If any
*
Please upload medical documents (if any)
Browse Files
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Consultation Appointment :
Asia/Kolkata (
00:00
)
300 ₹ Pay Now
