Date of Birth

Patient Name (required)

Email (required)

Phone

Delivery Address

Step-1. Medical Symptoms.
DepressionSeizuresPainAnxietySpasmsPanic attacksJoint discomfortInsomnia/SleepingMemory LossHeadachesNervousnessStressO Neck or Back TraumaCramps

Please Upload Your State-Id Here

Please Upload Your Medical Records Here (If you have any)

Please tell us more details about specific medical conditions and any other information that might be useful for the doctor to make a decision.