Title *
-- Choose option --MrMrsMissDrProf.

Full Name *

Preferred Name *

Postal Address *

Contact Number *

Profession *

Date of Birth *

Last visit to Lotus Villa *

Do you take Medicines at present? *
-- Choose option --YesNo

Do you take alcohol regularly? *
YesNo

Do you smoke? *
YesNo

Have you ever had/have treatments for the following conditions? *

• High Blood Pressure
  YesNo

• Diabetes Mellitus
  YesNo

• Heart Disease
  YesNo

• Kidney Disease
  YesNo

• Mental Condition
  YesNo

• Hormone deficiency
  YesNo

• Malignancy (Cancer)
  YesNo

Have you had any other Health issue since last visit to Lotus Villa? *

-- Choose option --YesNo

Have you had the corona viral infection (Covid-19)? *
-- Choose option --YesNo

Date of the last PCR test (if applicable) *

Status of the last PCR test? *
NegativePositive

Do you have any Medical reports regarding present health issues? *
-- Choose option --YesNo

Your main purpose of this consultation?

Online Consultation Procedure

Please select your convenience day *
-- Choose your convenience day --MondayTuesdayWednesdayThursdayFridaySaturdaySunday

Please mention your convenience time (German time) *
-- Choose your convenience time --08.00 a.m. to 10.00 a.m.10.00 a.m. to 12.00 p.m.12.00 p.m. to 02.00 p.m.