Checkout form for Health Plus Monthly billing

Subscription Plan

Health Plus - $40/month

Client Overview

Full Name

Date of Birth

Gender

Nationality

Contact Number

Email Address

Current Country / City

Destination Country / City (if known)

Preferred Dates (for appointment/travel)

Reason for Consultation / Treatment

Any existing medical reports (file upload, PDF/JPG)

Current medications / allergies

Urgency level (Routine / Semi-Urgent / Urgent)

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