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
1. I hereby voluntarily consent to be treated by FTR (Finger Tip Revolution) and/or equivalent Herbal medicines derived by FTR method and prepared Homeopathically suggested by IIHCC Free Medical Consultant. I understand that FTR is to be done by myself with my own finger tips as advised by IIHCC Free Medical Consultant, in an attempt to improve the body function and/or relieve pain. I acknowledge that no side effects would be possible, as it involves my own finger tips and/or the equivalent Homeo medium potency (3X to 12X) medicines I accept the fact that no guarantee is made concerning the use of FTR and/or equivalent suggested medicines. I understand that I may stop treatment at any time. I acknowledge the fact that IIHCC Free Medical Consultant does not profess to be a western-trained medical doctor and does not advise on the use of medically prescribed pharmaceuticals or medical treatment, nor does the IIHCC Free Medical Consultant give any substances by injection. I received completely free consultancy (no consultation fees). The clinical data gathered in practice, without names, may be used for statistical research and teaching purposes. I have been asked not to discontinue my present medication.

2.

Please Affix Photo here

3.

4. 5. 6.

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

ailment.

7. 8. 9.

Signature Name: Date: