Registration form for in person consultation - Hair
Email address *
Symptoms of corona virus disease 2019
Have you had fever, sore throat, bodyache, cough, breathlessness etc. in the last two weeks *
If yes, was the RT-PCR Covid - 19 test done *
Was the COVID - 19 test positive *
Anybody in your family / close contact have the above symptoms or were tested for COVID - 19 *
Is your residential area in a containment zone *
Have you traveled out of the city / state in the last three weeks *
Age *
Gender *
*
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First name *
Last name *
Contact details *
Address
Address line 1 *
City *
State *
Country *
Pin code *
Phone number Cellular *
Hair complaints *
Required
Any other complaint other than above. If not applicable please put NA *
Duration of complaint in days/weeks/months/years *
Treatment taken in the past for the complaint *
Any episode of major illness, fever, surgery, hospitalization etc. in the last 3 months *
Presence of any medical conditions like diabetes, hypertension, heart disease, obesity etc. *
Any family member (genetically related) having hair loss / baldness *
Preferred date and time for consultation. Currently the patients are seen with prior appointments. No walk-in consultations. *
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You agree to the contents of the terms and condition and consent form available at https://hairrevive.com/consent-in-person-consultation/ *
Required
A copy of your responses will be emailed to the address you provided.
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