|
|
|
|
| |
You are requested to mail us the details according to the Proforma given below along with the specified photographs for the consultation. Mails with complete details will be considered for the consultation and only genuine concerns will be addressed
For any reason, if further information is required a second form will be sent to you.
Most of the times our online consultation is free but a selected few might be charged (Rs 500) depending on our discretion.
| |
|
| |
| Due to technical problems in photo uploading, we have changed the Online consultation form into a sample proforma. Please submit your photos as specified below along with the details and mail us. We regret the inconvenience caused. |
| |
| PROFORMA FOR CONSULTATION |
| |
|
| NAME: |
|
| |
|
| AGE: |
|
| |
|
| SEX: |
|
| |
|
| ADDRESS: |
|
| |
|
| CONTACT NO’S: |
|
| |
|
| E-MAIL ID: |
|
|
Since how long you are loosing hair? |
|
|
| Hair loss history in detail |
|
| |
|
| Any other health problems? For e.g. bleeding problems, Keloid tendency, hypertension, diabetes and any known drug allergy etc. |
|
| |
|
| Family history of hair loss. |
|
| |
|
| Are you on any other medication? |
|
| |
|
| Your expectations from us: |
|
|
|
|
|
|
