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Basic Information Form for Consulting Service
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Please try to give us more detail information to let our Service Experts can serve you better.

Full Name
Please type your full name.
E-mail (*)
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Consulting Service for (*)
Please specify your position in the company
Please choose what kind service you need, so, our special Department Specialist can serve you better
If you are Allergy to any food or medicine
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If you are Allergy to any food or medicine
what kind of help you wish to get from us?
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what kind of help you wish to get from us?
Family Possible Sick Factors
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Please let's know if you know there is/are Family related Sickness may affect you. For example if your Father or your Mum has Diabetics or high Blood Pressure?
Birthday and Blood Type
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Tell us only if you Require Health Horoscope Consulting Service from us.
Height, Weight and Blood Pressure
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Please let's know your Height, Weight and Blood Pressure Information.
Problem in Detail
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Please let us know in detail: 1. when and what health problem you got. 2. what treatment and Medicine you once tried or currently you are taking.....
How should we contact you?
Please choose you preferred communication method.
When would you like to be contacted?
Please select a date when we should contact you.
Attach Related Reference Information
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Attach Related Reference Information, you can send us something Medical Exam Report to help us serve you better.
Captcha Antispam (*)
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