Ask Dr Rajesh Shah, MD Homeopathic Doctor in Mumbai at Life Force Homeopathy Clinic

Patient Screening cum Registration Form

* All Fields Are Mandatory

OR
(Provide Date of Birth or Age in Years & Months)

Patient Gender* :

Male

Female

AUTHORIZATION FOR TREATMENT, PROCEDURES, AND PAYMENTS

I have been informed and have understood that the detailed history of my suffering is required for diagnosis and selection of homeopathic medicine for my treatment. By signing these preliminary details form and by starting the treatment, it is agreed by me that I have granted my irrevocable and unconditional consent to the doctors of Life Force Homeopathy (under care of Homoeopathy India Pvt Ltd ) to note down and store my medical details, pictures of the diseased parts required for diagnosis and evaluation, audio video record of interaction for quality control for educational and training purpose. The photographs and videos of me can be used for educational, illustrative, promotional, and training purposes, without disclosing my identity. However, I have an option to deny the use of my videos for any purpose other than my treatment.

I have understood that the treatment will be focused on a certain disease or diseases for which I am subscribing. The treatment for additional disease would be charged separately.

Refund policy: I have been informed about the refund policy (as per the copy on the Life Force websites), which I agree with. The telephonic support is available only with associate doctors.

SMS send email: I am permitting to send me SMS/email on my registered mobile, such as for visits, dose reminders, etc. I will have an option to stop this facility by choosing an option in the Patient Support System.

I certify I had the opportunity to ask questions and have them answered, and I accept the terms and conditions, and I agree to pay all charges for which I may be legally responsible to pay.

No Guarantees: Though you will evaluate and treat my case professionally, I fully understand that the outcome of the treatment is subject to internal and external factors beyond our control, and there is no guarantee of success in terms of complete recovery of my ailments.

I/We here signed the above on my/our own free will after understanding fully the contents and the explanations given to me/us by the Life Force Clinic authorities, including the doctors.