AYURVEDIC LIFESTYLES INC.

ONLINE CONSULTATION  
The only science of real LifeStyles.  SERVING YOU SINCE 1988 with Classical touch of Divinity.

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  • "ONLY SERIOUS INQUIRIES, PLEASE"

  • Fee: $ 100.00 Canadian Dollars

  • Payment: Strictly Credit Cards (we will phone you to ask your credit card information).

  • As per "Submitting" this form, upon receiving of your form, we will call to confirm your information only and next compulsory step is that you will provide us your "Credit Card" information, then only we can process your treatment plan, if you will fail to do it, we will discard your "Online Consultation Form"

  • Please provide more information, it will be better for us to give you proper advice and/or guidance.

 

Field marked by * (star), Must be Filled Out. 

* Name

First Name                       Last Name

* Sex Male Female
* Age

* Date of Birth : 

(yy/mm/dd)

Profession
 

* Address

Example of Address:

1115 O'CONNOR DRIVE

Toronto, Ontario, Canada

M4B 2T5 (pin code/ zip code)

* Email
* Email Verification
* Phone * Fax
* Business * Cell
* Marital Status Married Unmarried
Single Divorced
   
* Blood Pressure (if you are not sure then type High / Normal / Low)
* Weight lbs (kgs x 2.2)
* Height Feet Inches
* Urine Clear Cloudy   Color
* Toilet (stool) Hard  Semi Liquid  Normal Color 
   
* Women only  
* Periods Info.:  
-Frequency
Regular    Irregular 
-Clots
Yes     No 
-Painful
Yes     No 
-Flow
Normal High
* Are you Pregnant Yes No  , if "YES" Due Date (yy/mm/dd)
   
Are you a Vegetarian Non-Vegetarian
* Addiction Alcohol Drugs
Smoking Coffee
  Tea

* 1)Major  Complaint(s) and

* 2) How old is the problem(s)
* Personal Health History
* Are you currently taking any medication
* Are you currently taking any vitamins or herbs
* Other information which you think might be helpful

 

I understand the assessment of my health problem(s), and providing all information above is correct to get right health advice from Ayurvedic Lifestyles inc.  with personal interest. It is entirely my choice of these services. I am / will agree with Ayurvedic Lifestyles inc.'s  terms & conditions.

* Today Date: (yy/mm/dd)

 

Payment: Strictly Credit Cards (we will phone you to ask your credit card information) and we may charge for frequent telephone conversation on hourly basis.

Note: if you won't reach to the "Form Confirmation Page", please click again on SUBMIT. Thank you.

Send mail to AyurvedToronto@sympatico.ca with questions or comments about this web site.                                                       
Copyright © 2004 - 2013 Ayurvedic LifeStyles Inc.
Last modified: 12/07/11

 

Disclaimer-Warning: The information on this Website is provided for general informational purposes only and SHOULD NOT be relied upon as a substitute for sound professional medical advice, Information on this website is can not be evaluate or examine, because it has been collected from various sources.  If you have a medical problem or a health-related question, consult your physician or call 416- 778-9341.