Consultation Appointment Form Title * -- Choose option --MrMrsMissDrProf. Full Name * Preferred Name * Postal Address * Contact Number * Profession * Date of Birth * Height * Weight * Last visit to Lotus Villa * Do you take Medicines at present? * -- Choose option --YesNo If yes, please mention relevant Health issues * Do you take alcohol regularly? * YesNo Do you smoke? * YesNo Have you ever had/have treatments for the following conditions? * High Blood Pressure YesNo Diabetes Mellitus YesNo Heart Disease YesNo Kidney Disease YesNo Mental Condition YesNo Hormone deficiency YesNo Malignancy (Cancer) YesNo Have you had any other Health issue since last visit to Lotus Villa? *-- Choose option --YesNo If yes, please mention relevant Health issues Have you had the corona viral infection (Covid-19)? * -- Choose option --YesNo If Yes, please mention any complication or aftereffects regarding your health condition * Date of the last PCR test (if applicable) * Status of the last PCR test? * NegativePositive Do you have any Medical reports regarding present health issues? * -- Choose option --YesNo If Yes, please attach copies * Your main purpose of this consultation? Online Consultation Procedure Please select your convenience day * -- Choose your convenience day --MondayTuesdayWednesdayThursdayFridaySaturdaySunday Please mention your convenience time (German time) * -- Choose your convenience time --08.00 a.m. to 10.00 a.m.10.00 a.m. to 12.00 p.m.12.00 p.m. to 02.00 p.m.