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Sai homoeopathic clinic
A consulting service at comfort of your home.
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Full name
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Email
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What is your age?
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Contact details (what's app & email id)
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Address
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Chief complaint since when? (any disease 2 year)
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Any medicine that you take daily? If yes write name of medicine
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Do you have any lab reports with you? If yes then send it to
healingorcuresaihomoeoclinic21@gmail.com
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Do you give consent for homoeopathic tale consultation with Dr. Priyanka Raikwar
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