Forms Good Karma Initiative Kindly complete the form belowHospital detailsForm Filler Name *Please enter the name of the person completing this formContact Email *Phone *Any additional informationPatient Reference *Consent *Yes, I agree with the privacy policy and terms and conditions.Patient ConsentConsent for Video Testimonial: Patient hereby grants consent to Maxwell Investments Group Ltd to use his/her video testimonial for promotional and educational purposes. *Yes, Patient consentsNo, Patient does not consentChoice for Visibility: Please select one of the following options regarding the visibility of your face in the video testimonial. *I consent to the display of my face in the video testimonial.I do not consent to the display of my face in the video testimonial. I prefer my face to be obscured or hidden.Write your Patient Testimonial *Upload your files *Drag and Drop (or) Choose FilesPlease upload video or document. Maximum 2 files per submission up to 8mb each in sizeSUBMIT FORMPlease do not fill in this field.
