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Libra Health

Contact us for Ayurveda online consultancy

Please fill up this form if you are willing to come to our clinic for consultation and proper Ayurveda Panchakarma Treatment.

Fill in the following details. If possible, send a copy of your medical reports viz. Blood Report, X- Ray, CT Scan, MRI, etc.
by email or normal mail. Kindly give the proper details for better diagnose.
* - Compulsary Fields

 
Your Complete Name:*
Date of Birth: *
year
Single / Married *
Single
Married
Email Address: *
Occupation and Nature of work:
Present Diagnosis and Treatment (if any)
Question / Health Problem Query
Past History(Previous problems & surgery
Any chronic illness like Diabetes / Hy.tension / TB / Heart Diseases / & medicine taken now:*
Your Weight:*
Phone Number with ISD-STD code: *
Postal Address: *
Country / State / District / PinCode *
 

 


     

 
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