CASE REGISTRATION FORM

Please provide the following contact information:

First Name
Last Name
Middle Initial
Title
Organization
Street Address
Address (cont.)
City
State/Province
Zip/Postal Code
Country
Work Phone
Home Phone
FAX
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Please provide the following payment information:

You can make the Payment of Consultation including Medicine Charges at my State Bank of India Branch Parbhani Account No: 11183371225. Or You can make Payment by National/International DD in favor of 'Dr. Pawan S. Chandak' payable at Parbhani.

	Mode of Payment
Payment through	International DD Nationalised Bank DD Account Transfer
Payee's Name
DD/Account No.
Date

        Please identify and describe yourself:

First Name
Last Name
Middle Initial
Date of Birth
Sex	Male Female
Height
Weight

I want to Consult for Skin Problem Eczema Psoriasis Lichen Planus Vitiligo Hair Loss Alopecia Baldness Dandruff Urticaria Fungal Infection Ringworm Tinea Versocolor Acne/Pimples Allergic Rash Dark Circles Sexual Problems Infertility Sexual weakness Azospermia Oligospermia Stress Anxiety Depression Sleeplessness Forgetfullness Loss of Memory Mania Acidity Constipation Piles Fissure Chronic Cold Sinusitis Asthma Allergy Backachae Arthritis Gynecological Problems Irregular menses Leucorrhoea Renal Calculi Uterine Fibroid Overweight Loss of weight Migraine Visual disturbance

 

Please contact me as soon as possible regarding this matter.