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FTR Registration Form 'English' Latest
FTR Registration Form 'English' Latest
A.
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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.
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All above data are given at my free will and I approached the ashram on my own for my
ailment.
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