Online Registration

The Ayush Samiti / Online Registration

Please submit your details using following form for online registration of patients.

Registering Fee is Rs. 1,000 one time only.
After submitting the form, you will be presented with a Payment button to make the payment and confirm your Registration. You can pay using Internet Banking, Credit/Debit Card or UPI.
We will get back to you once your registration is confirmed.

Patient Registration form

Full Name:*
Gender:*
Date of Birth:*
Address:*
City:*
Zip-Code/Pin-Code:
Country:*
Email-ID:*
Mobile No.:	(For eg. +91 – 9826734351)
Landline No.:	(For eg. +91 – 788 – 4086338)
Medical Investigations:*
Current Physical Conditions:*
Age:*
Height:*
Weight:*
Marital Status:*	Married Unmarried
Children:
Diet:
Appetite:
Alcohol:
Smoking:
Sleep:
Bowel Habits:

Please submit your details using following form for online registration of patients