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International Integrated Holistic Cure Centre (IIHCC)

FTR Therapy Registration Form

A.

Personal Details 1. 2. Name Birth Details / / Time Of Birth (24)(hrs min) Place Of Birth (Village, City, State)

Date Of Birth (dd/mm/yyyy) 3. Contact Address

City 4. 5. 6. 7. Contact Nos E Mail ID (if available) Qualification / Profession Who referred you to this office? Land Line

State Mobile No

PIN

B.

FTR Details : (allotted by IIHCC)

Patient ID

Enter the FTR prescribed to you

Enter the FTR experience Feedback to be given

I I H C C No. 95, 20th main,8th cross, G-Block, Sahakara Nagar, Bangalore 560092, India Website: www.ihhp.net Email: ihhp.blr@gmail.com Tel : +91 934 122 1944, 080-23532184 For IIHCC use Only: Registration received / Patient ID : Reference Folder : Allotted Date/ Sign:

International Integrated Holistic Cure Centre (IIHCC)

FTR Therapy Registration Form


C. No Past Ailments (Use separate sheet if required Complete Information Required) Disease Name Treated Where Medicines Taken Dosage Present Status

D. No

Present Ailments (Use separate sheet if required Complete Information Required) Disease Name Treated Where Medicines Taken Dosage Present Status

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

Signature ( Name: Date :

I I H C C No. 95, 20th main,8th cross, G-Block, Sahakara Nagar, Bangalore 560092, India Website: www.ihhp.net Email: ihhp.blr@gmail.com Tel : +91 934 122 1944, 080-23532184 For IIHCC use Only: Registration received / Patient ID : Reference Folder : Allotted Date/ Sign:

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