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International Integrated Holistic Cure Centre (IIHCC) FTR Therapy - Preliminary Registration Form

IIHCC Ref Patient ID

A.
1 2a 2b 2c 3a 3b 3c 4

Patient Details
Name DOB TOB POB Phone LL Mobile 1 Mobile 2 E Mail ID 5b 5c 5d 6 7 City State Pin Code Ref by Qual / Profession 5a Address

B. No

Details of Ailments (latest First) (Use Reverse Side / Separate sheet if required) Disease Name Treated Where Medicines Taken Dosage Present Status

C. Patient Declaration Please Affix Photo here

All above data are given at my free will and I approached the ashram on my own for my ailment.

Signature Name: Date:

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