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