Dear Patient,

You may submit your physical problems through this form and consult Dr. Rajiv Verma, an expert in alternative medicines. It is a paid service and the charges are just $50.00 for the full consultation.

Name			Date of Birth (as 23-May-1967)
E-mail			Time of Birth (as 13:30)
Telephone			Place of Birth
Fax
Postal  Address			Physical Problems