Registration Form – Sharda Swasthya Mission

Skip to content

Sharda Swasthya Mission

Sharda Swasthya Mission

Home
About Us
Treatment
Pre-diagnosis
Cases
REGISTRATION

Registration Form

Name *

First

Last

Age *

Gender *

Female
Male
Other

Email *

Whatsapp Number *

Complete Address *

Prescription *

1st Prescription for Indians : 1500/- for 2 months
1st Prescription for others : 50$
Subsequent Prescription (Indians) : 300/- each for 1 year
Subsequent Prescription for others : 18$ each for 6 months

Brief Description of your Symptoms *

Facebook Instagram Google

Registration Form