Enquiry Form

This is one way of indicating your desire to take things further. After completing this form, it will be sent to the Maharaj Institute of Immune Regenerative Medicine where it will be reviewed and then we will be in touch to discuss your personalised treatment.

Name *

Current active medical conditions and approximate onset

E-mail *

Contact telephone number *

Date of Birth

Current Medications

Past significant medical history

Any planned new treatment

What do you hope the Maharaj Institute of Immune Regenerative Medicine can help you with *

This information will be treated as strictly private. However please indicate your consent for this to be reviewed by the staff of the Maharaj Institute of Immune regenerative medicine *