Name:

Email:

Phone Number:

Preferred Day/Date/Time: Available days: Friday, Saturday, Sunday

Your Issue:

Doctor Fee: Rs. 1000

Please pay via:

• 📱 JazzCash/EasyPaisa: 0300-XXXXXXX (Account Title: Aura Bloom)
• 🏦 Bank Transfer: Bank - 1234567890

Transaction ID / Reference #