Registration form for remote consultation - Hair
Email *
Age *
Gender *
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. 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/ *
Required
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