Registration-Form

Patient Registration Form

Prefix *

* Indicates required field

Name *

First

Last

Gender *

Occupation *

Phone number *

Email *

Postal Address *

City *

State *

Country *

ZIP / PIN *

Your Photo *

Max file size: 20MB

Passport Number *

Photo of the Passport with your details *

Max file size: 20MB

Date of Expiry of Passport *

Date of Expiry of Visa *

Photo of the Indian Visa *

Max file size: 20MB

Date of Admission (DD/MM/YYYY) *

Expected Date of Discharge (DD/MM/YYYY) *

Comment *

Submit

This is a patient registration form which is to be filled and submitted after you have made your advance payment and your reservation at vaidyagrama has been confirmed.
This form may be submitted before you arrive in vaidyagrama.
The above is required for online submission to the local authorities in India as per the prevailing laws in India.
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ACCREDITED

Hospital

Vaidyagrama Ayurveda Healing Village
A unit of Punarnava Ayurveda Limited
15(1) Rottikaranur Road,
Thirumalayampalayam Post, Madukkarai via, Coimbatore, Tamilnadu 641105, INDIA

Admin

Punarnava Ayurveda
A‐21, Parsn Galaxy, Nanjundapuram Road, Coimbatore‐ 641036. Tamilnadu INDIA.

PHONE

+91 422 2364200
Tollfree Number in India: 18001232230