Free Health Consultation

Please fill up this form to get free health advice . Write to us about your disease or health concern . Your information will be kept private and highly confidential. By requesting for Free Health advice by GGN CLINIC you acknowledege and agree that the diagnosis you will recieve is limited and provisional , this web based opinion is not intended to replace medical evaluation which consist of physical examination. As we are not able to do the physical examination , it can affect our ability to make a accurate diagnoses and you agree and acknowledge the risks of these limitations. No guarantee or warranty has been made to you , concerning any result or cure of your condition.And if we are not able to understand your health concern by the data you have submitted in the form , we may not reply. You should be above 18 years to fill up this form.

* Required

Name * provide us with the patients name ( or any nick name , if you want to keep it more confidential)

Age *

Sex *

Male
Female

Race/Ethnicity * American Indian/Asian/Black or African American/Hispanic/Latino/White/Others.

Do you smoke ? If yes for how many years and how many packs a day you are smoking? * Write Yes or NO , If Yes then write the details.

Do you take Alcohol? If yes , then tell us how many drinks and what you drink and for how many years? * If No , just write NO , no details.

Do you have any allergies ? Any allergies to medications or any any other thing like pollens , cat fur etc. * If NO , Just write NO and no details are needed.

Write about your disease in detail ? If we need any hard copy of your report , we will let you know by email? * Tell us when the symptoms first appeared , how they progressed , what medications are you taking , do you have history of diabetes, hypertension , arthritis , Tuberculosis, HIV,/ Have you been admitted in hospital before also for any other medical condition / Any tests were done , tell us about the tests and procedures which are already done etc .

Email Id * to contact you for details and advice .