Doctor Consultation

Provide us your basic details...

Email Id*

Name*

Gender*

Age*

Weight*

Height*

Phone No.*

Food type*

Habits*

Mode of Transport*

Provide us your medical history...

Any ongoing medical condition ?*

Any ongoing medication*

Prior medical history ?*

Present complains(related to hair)...

Hair fall*

Duration*

Severity*

Hair Breakage*

Duration*

Severity*

Dandruff*

Duration*

Severity*

Hair Greying*

Duration*

Severity*

Hair fall type*

On an average how severe is your hair fall *

Any other specific hair related problem ?*

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