Register Now: PHC Disease Reversal Program
Thank you for your interest in Reversing Disease & Gaining Health! Looking forward to meeting you soon and sharing the secrets of Naturopathic Whole Food Plant Based diet & Natural Lifestyle with you! :)

Please register by filling this form. If you have any questions, please feel free to contact us at +91 9483421942 or

CONTRIBUTION: Rs. 12000 per participant.
# Early Bird Discount: Rs. 1500 off if you complete your registration by transferring your contribution before midnight, September 1st!

PLEASE NOTE: One of us will get in touch with you once you fill this form, to confirm your registration. Filling this form does not confirm registration, as we need to check eligibility before confirmation.

Thank you! Be blessed! :)
- Punarpoosam Health Care
Empowering you to #BeYourOwnDoc through Naturopathy & Yoga

My name is *
Your answer
My age is *
Your answer
Mail me at *
Please provide your Email ID
Your answer
Call me at *
Please provide your mobile number (without +91 or 0)
Your answer
I or we would like to come on: *
Please select Program date
Please write briefly about the health issues you are facing at the moment, which you would like to reverse through this program. *
Your answer
What medications are you taking at the moment? Please include dosage of medications, supplements, insulin and any other therapies you are undergoing at the moment. *
Your answer
How did you come to know about this disease reversal program? *
If you have any question, clarification or comment, please write to us here.
Your answer
Never submit passwords through Google Forms.
This form was created inside of PHC Lifestyle Clinic. Report Abuse - Terms of Service - Additional Terms