Vd. Ranjeet Sharma's PAID Consultation Form.
You may fill this form in Hindi / English. ( HINDI - Aap Is form ko Hindi Ya English Bhasha me bhar sakte hain).

CONSULTATION FEE:
WITHIN INDIA : Rs.200/-
NRI & FOREIGNERS : USD 25/-

This Consultation fee entitles you for:
03 INTERACTIONS with the doctor WITHIN a period of 07 DAYS.
INTERACTION means EMAIL interaction, AUDIO or VIDEO MOBILE CALLS, whatever suits the requirement of the patient.
Eg.- We prefer VIDEO CALL for a PSORIASIS or ECZEMA patient.
The day counting starts FROM THE DAY WHEN YOU RECEIVE FIRST RESPONSE FROM THE DOCTOR.

HOW TO SUBMIT THE FEE:
#PAYTM at MOBILE : 09454351536. Whatsapp the Screenshot of the transaction to the same mobile no. mentioning your name & other details.
#You may also submit the fee in below given account:
ICICI BANK
Ankita Sharma
Ac. NO. - 628201558363
IFSC - ICIC0006282
Whatsapp the SCREENSHOT of the transaction to the mobile no.- 09454351536 mentioning your name & other details.

After submission of the consultation fee, Please fill this form and submit.
We request you please to describe your health issues in detail (in HINDI or ENGLISH). It will help us plan your treatment in a better way and reduce our conversation time.

In case of any problem, you may WRITE OR MESSAGE US at:
EMAIL : ramgoday@gmail.com
MOBILE : 09454351536, Only for Whatsapp or messages, PLEASE DO NOT CALL.
Email address *
Please mention here consultation fee TRANSACTION DETAILS ( Paytm or Bank Account transfer, Name, Transaction ID etc.) *
Your answer
Your Moble Number ( we will call you on this mobile no) *
Your answer
Name, Age, Sex (Male / Female), Unmarried / Married. *
Your answer
Your Present Residential Location (Eg.- Allahabad, U.P.) *
Your answer
Please Describe your Health Problems in detail. (HINDI : Apni swasthya samasya ko puri jankari yaha likhiye) *
Your answer
Please click the checkbox, if you suffer from any of the following: *
Required
Are you taking any treatment (allopathy / Ayurveda) for your problems? If yes, please give the details. Name of the medicines must be mentioned *
Your answer
if there is any family history of any disease, please describe it here. *
Your answer
Mode of your Job / Profession (Sedentary or walking/ standing, day / night hours, level of stress etc.). Please fill this section carefully because your job is often found to be very much connected with your health issues. *
Your answer
In case you wish to furnish some more information, please do it here. *
Your answer
A copy of your responses will be emailed to the address you provided.
Submit
Never submit passwords through Google Forms.
reCAPTCHA
This content is neither created nor endorsed by Google. Report Abuse - Terms of Service - Privacy Policy