Immunity Booster Program
Kanaka Prashana / Suverna Prashana Program Inquiry Form
Parent Name
*
First Name
Last Name
Child Name
*
First Name
Last Name
Age
*
Age limit 16 years
Height
You want to Consult Dr. Ashish
*
Online
In Person at Bandra (Mumbai) Clinic
In Person at Vasai Clinic
Kanakaveda's Referance You Got From
*
Google Search
Kanakaveda's Patient
TV Interview
YouTube
Relative
Email
example@example.com
Mobile Number
*
-
+91
xxxxxxxxxx
City
*
Consultation - Rs. 2000 /-
Please Select A Program from below, according you will get detail information.
*
3 Monthly Program (Rs. 20000/-)
6 Months Program (Rs. 36000/-)
12 Months Program -(Rs. 69000/-)
Courier Charges applicable Domestic
3 Months - Rs. 300/- | 6 Months- Rs. 600/- | 12 Months - Rs. 1200/-.
Courier Charges for International as per actual.
Signature
*
Submit
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