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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.