QUERY FORM
* (PLEASE PROVIDE AS MUCH DETAIL AS POSSIBLE) *


Title * :
First Name * :
Last Name * :
Age * :
Country * :
Postal Address :
  
Home Telephone * :
(Include Country & Local Code)
Mobile Telephone :
E-mail Address * :
Confirm Email Address * :
  
When is it most convenient to contact you?
:
  
What type of treatment are you seeking information on? *
   Orthopedics
   Cardio Surgery
   Cosmetic Surgery
   Dentistry
   Ophthalmology
   Obesity / Bariatric Surgery
   Dermatology
   Oncology / Radio Therapy
   Neurosurgery
   Urosurgery
    Nephrology
   Gastro-Enterology
   General & Endoscopy Surgery
   Laparoscopy
   ENT Treatment
   Internal Medicine
   Pediatrics
   Cryosurgery
   Health Checkups
   others
  
Please specify * :
  
Please provide additional information that would help us assess your requirements *
  
i.) 'Do you suffer from conditions like BP, Diabetes, Hypertension OR Any other condition'
    (Please answer in detail):
  
ii.) Are you currently taking any medications (Please specify):
  
iii.) Have you undergone any surgeries of late (Please specify):
  
When would you like to have your treatment? (please specify month)
  
Besides the treatment you are seeking, do you wish to have any other health consultations?
   Yes         No  
  
Would you like us to organise flights and accommodation for you?
   Yes         No  
  
Would you like us to organise visas for you?
   Yes         No  
  
Would you be accompanied by a relative or a friend? *
   Yes         No  
  
Where did you hear about us? *
     Internet                  Magazine

FamilyOrFriend  Other      
What Hospital or Surgeon you would like to get your treatment from ?
  
Do you have any other questions or comments?
  
 
   Agree to Terms and Conditions *
  

Treatment In India