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The Doctor :Please manage to supply the required doses under your terms, directions and jurisdictions to the undernamed as per given particulars against its fee.
Subject        :
  M/E Date :
Name(Caps) :
Address       :
Pin              :     Phone     :
Age (Yrs.)    :
Male     Female
Height(Cms):
Married    Unmarried
Weight (Kg) :
Student   Service
Professional Bussiness
Height gain after H-Stop : Yes No  
Any Method Tried Before: Yes No
Mode 0f Payment: DD MO     DD No.
Amount     Rs.       $          €      £
Course/Pkg. :     Short-C:3M     Half-C:6M              Full-C:1Y
Brief History (if any)