Order Consultation - Pre-evaluation Form Please enable JavaScript in your browser to complete this form.Registration e-mail *This e-mail will be used to verify your payment and your appointment with our specialistSession Type *Audio and Video CallAudio Only CallFull Name *FirstLastCountry of Residence *Age Selected Value: 30 Marital Status *SingleMarriedDivorcedWidowedNumber of Dependents (Children) Selected Value: 0 Occupation (if applicable)Specify if you use alcohol or any illicit drugs, if not keep emptySpecify if you have any diseases (e.g. Hypertension, diabetes etc..)Main Complain *Preferred day of week for the session *SundayMondayTuesdayWednesdayThursdayFridaySaturdayWe will confirm the session date with you in the appointment details e-mail.Preferred time for the session (GMT) *03:00-05:00 PM05:00-07:00 PM07:00-09:00 PM09:00-11:00 PMWe will confirm the session time with you in the appointment details e-mail.Agreement (Please read carefully) *I agree on the following terms and conditionsI confirm that all above information are correct. This is a booking for one online session only for up to 30 minutes. To reschedule, send an e-mail to accounts@psychiatric-onlineclinic.com at least 2 days prior to your designated session date. If you do not show up on the designated session date and time, you will have the option to reschedule your session for a later date If your Internet connection during the session is disconnected or interrupted, we are not obliged to return, compensate or repay you any amount. However, we might consider rescheduling your session for a later date Refund or cancellation is not accepted after conducting the session If you want to refund and cancel this booking, you need to send an e-mail to accounts@psychiatric-onlineclinic.com requesting for a refund or a cancellation mentioning your reason before at least 2 days prior to your designated session date If you request for a refund of a cancellation, extra charges and fees are applied to your amount. Money refund duration could take up to 90 days or more when issued by our payment processor.CommentBook Now