Easymom,
                    Plot 1A, Mambakkam Main Road, Medavakkam, Chennai. .
                    
                                    REQUEST/CONSENT FOR CONSULTATION / ADVICE / treatment
      AS PER IMA SCHEDULE                      DATE:-              TIME:-  
      
      PLACE:-       PATIENT AGE:        SEX(tick):           MOBILE NUMBER:-
      

      I/We   , will be explained by my/our physician, that i am/ we consulting doctor for current illness/advice/treatment 


      I/We voluntarily give consent, of my/our free will, for the consultation or any treatment or any advice for all the communications with the doctor. I/We also understand that there is no guarantee of success of the said advice/treatment. 

      I/We acknowledged that once fees paid for all services will not be returned back by any means. Explained by the patient's understandable language.