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+91 90162 04242
rpsing512@gmail.com
Opp. Tarak Online, Bus Stop Road, Lakhani, Banaskantha 385535
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Medicine Free Bharat Registration
Full Name *
Gender *
Select Gender
Male
Female
Other
Age *
WhatsApp Number *
Mobile Number *
Email
State *
City *
Pincode *
Full Address *
Current Health Issue *
Select Issue
BP
Thyroid
Obesity
PCOD / PCOS
Acidity
Other
Are you on medication?
Select
Yes
No
If yes, which medicines and since when?
Duration of Illness
Select Duration
Up to 6 months
1 year
1 to 5 years
More
Health Goal
Select Goal
To become medicine-free
To lose weight
To adopt a healthy lifestyle
Other
Service Plan
Select Plan
Basic Plan
Silver Plan
Gold Plan
Not sure – I need guidance
Preferred Service Time
Select Time
Morning
Afternoon
Evening
Night
Flexible
How did you hear about us?
Select Option
WhatsApp
Facebook
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YouTube
Friend / Family
Other
Would you like to become a Health Coach?
Select Option
Yes
No
Special Note or Question
Note:
You will be contacted within 24 to 48 hours after submitting the form.
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