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1. The document is a preliminary registration form for an alternative holistic treatment center called the International Integrated Holistic Cure Centre (IIHCC). 2. It collects patient information like name, contact details, medical history, and treatment consent. 3. The patient consents to be treated with Finger Tip Revolution (FTR) therapy, a method where the patient uses their own fingertips, or equivalent homeopathic medicines, acknowledges there are no guarantees but they can stop treatment at any time.

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R_prelim_app_Rev6_SVM_040313 visit www.ihhp.net for details - mail Id:: ihhp.blr@gmail.com IIHCC Ref WS Patient ID App. Ref Habits : Non-Veg [ ] Alcohol [ ] Tobacco/Gutka [ ] Egg [ ] ( check all that are applicable) Any Other : A. Patient Details 1 Name 5a Address 2a Date Of Birth 2b Time Of Birth 2c Place Of Birth 5b City 3a Phone LL 5c State 3b Mobile 1 5d Pin Code 3c Mobile 2 6 Referred by 4 E mail ID 7 Qualification / Profession B. Details of Ailments (latest First) C. Patient Declaration (Use Reverse Side / Separate sheet if required) No Disease Name Since Date No Medicines Taken Dosage International Integrated Holistic Cure Centre (IIHCC) No 95, 8th Cross, 20th Main, G Block, Sahakar Nagar, Bangalore 560 092 FTR Therapy - Preliminary Registration Form 1. I hereby voluntarily consent to be treated by FTR ( Finger Tip Revolution ) and/or equivalent Herbal medicines derived by FTR method and prepared Homoeopathically suggested by IIHCC Free Medical Consultant. 2. I understand that FTR is to be done by myself with my own finger tips as advised by IIHCC Free Medical Consultant, in an attempt to improve the body function and/or relieve pain. 3. I acknowledge that no side effects would be possible, as it involves my own finger tips and/or the equivalent Homoeo medium potency (3X to 12X) medicines. 4. I accept the fact that no guarantee is made concerning the use of FTR and/or equivalent suggested medicines. 5. I understand that I may stoop treatment at any time. 6. I acknowledge the fact that IIHCC Free Medical Consultant does not profess to be western-trained medical doctor and does not advice on the use of medically prescribed pharmaceuticals or medical treatment, nor does the IIHCC Free Medical Consultant give any substances by injection. 7. I received completely free consultancy (no consultation fees). 8. The clinical data gathered in practice, without names, may be used for statistical research and teaching purposes. 9. I have been asked not to discontinue my present medication. For IIHCC use only Prescription Please Affix Photo here Important Note: It is a Pre-requisite for undergoing FTR Process that the Beneficiary should totally abstain from any kind of Non-Vegetarian Food including Egg. I am aware of the above. All above data are given at my free will and I approached the ashram on my own for my ailment. Sign here Name: Date:

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  • 1. R_prelim_app_Rev6_SVM_040313 visit www.ihhp.net for details - mail Id:: ihhp.blr@gmail.com IIHCC Ref WS Patient ID App. Ref Habits : Non-Veg [ ] Alcohol [ ] Tobacco/Gutka [ ] Egg [ ] ( check all that are applicable) Any Other : A. Patient Details 1 Name 5a Address 2a Date Of Birth 2b Time Of Birth 2c Place Of Birth 5b City 3a Phone LL 5c State 3b Mobile 1 5d Pin Code 3c Mobile 2 6 Referred by 4 E mail ID 7 Qualification / Profession B. Details of Ailments (latest First) C. Patient Declaration (Use Reverse Side / Separate sheet if required) No Disease Name Since Date No Medicines Taken Dosage International Integrated Holistic Cure Centre (IIHCC) No 95, 8th Cross, 20th Main, G Block, Sahakar Nagar, Bangalore 560 092 FTR Therapy - Preliminary Registration Form 1. I hereby voluntarily consent to be treated by FTR ( Finger Tip Revolution ) and/or equivalent Herbal medicines derived by FTR method and prepared Homoeopathically suggested by IIHCC Free Medical Consultant. 2. I understand that FTR is to be done by myself with my own finger tips as advised by IIHCC Free Medical Consultant, in an attempt to improve the body function and/or relieve pain. 3. I acknowledge that no side effects would be possible, as it involves my own finger tips and/or the equivalent Homoeo medium potency (3X to 12X) medicines. 4. I accept the fact that no guarantee is made concerning the use of FTR and/or equivalent suggested medicines. 5. I understand that I may stoop treatment at any time. 6. I acknowledge the fact that IIHCC Free Medical Consultant does not profess to be western-trained medical doctor and does not advice on the use of medically prescribed pharmaceuticals or medical treatment, nor does the IIHCC Free Medical Consultant give any substances by injection. 7. I received completely free consultancy (no consultation fees). 8. The clinical data gathered in practice, without names, may be used for statistical research and teaching purposes. 9. I have been asked not to discontinue my present medication. For IIHCC use only Prescription Please Affix Photo here Important Note: It is a Pre-requisite for undergoing FTR Process that the Beneficiary should totally abstain from any kind of Non-Vegetarian Food including Egg. I am aware of the above. All above data are given at my free will and I approached the ashram on my own for my ailment. Sign here Name: Date: