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Online/Remote consultation for skin aesthetics
Form to be filled for online video consultation for skin aesthetics
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Email
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Your email
Full name starting with first name
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Your answer
Age
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Your answer
Gender
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Female
Male
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Address
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Your answer
Pincode
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Your answer
Cellular phone number
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Your answer
Skin complaints
*
Dull skin
Fine lines/wrinkles
Acne
Pigmentation
Other:
Any complaint other than above
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Option 1
Duration of complaints
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Your answer
Treatment taken if any for this complaint in the past
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Your answer
Any episode of major illness, fever, surgery, hospitalization etc. in the last 3 months
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Your answer
Presence of any medical conditions like diabetes, hypertension, heart disease, obesity etc.
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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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Your answer
You agree to the contents of the terms and condition and consent form available at
https://hairrevive.com/consent/
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