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Registration form for remote consultation - Hair
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Email
*
Your email
Age
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Your answer
Gender
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Female
Male
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First name
*
Your answer
Last name
*
Your answer
Contact details
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Address
Your answer
Address line 1
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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. We are available for consultation from Mon to Sat from 10 am to 1 pm and 5 pm to 8 pm
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You agree to the contents of the terms and condition and consent form available at
https://hairrevive.com/consent/
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