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If you are not able to send online form click here to download the consultation form in MS Word format .

 

ONLINE CONSULTATION FORM

  * Field are mandatory !

1.

General information :
 
* Name
* Age
* Sex Male Female
* Address:
(Type the correct address where you want your medicine to be sent)
* Phone No
* E-mail
 
2.

Discription of your problem in your words
 

 
3.

Which type of alopecia do you suffer ?

 

(Click here to see the photographs of different type of alopecia. )

Alopecia areata,
Alopecia totalis
Alopecia universalis
Male/Female pattern baldness
General hailoss
Others
Diffuse alopecia
Tricotillomania
Scaring alopecia
Chemotherapy and hairloss
Hairloss due to hair dye, hair colour, perming, straightening ect.
 
4.

Do you suffer any other medical conditions at present like...
 
thyroid
diabetes
hypertension
depression, stress
Irregular menstruation cycle
constipation
acidity
others
 
5.

Visual Examination:
 
Is the hair loss all over scalp ?
Yes
No
 
Is the Hair loss limited to the top of the
scalp, temples and occipital region ?
Yes
No
Describe..    
 

Is there dandruff, fungus, lice, nits
present on the scalp ?
Yes
No
 
Quality of your hair:
Normal Rough Thick Silky Oily
Uncombable Dull Thick and black Curley Dry
 
6.

Hair related lab reports:
 
Thyroid Normal Hyper Hypo
  Estrogen Progesterone Level Normal Imbalance
  DHT level
  Iron concentration Normal Anemia
 
7.

Quality of your hair
 
Dry Straight Thick
Brown Oily Curly
Black Blond Wavy
Brittle Gray    
 
8.

Photographs of the affected area with 2-3 different views
 

Attach photographs here:

1.

2.

3.

(the File size should not be more than 300 KB, File format should be .jpg, .gif, .tif, .png, .pcx or .bmp only)

If you don't have any photograph, please see the page "what is alopecia" and mention picture no. of what is alopecia match with your problem.

Picture No.

Picture No.

Picture No.

 
9.
Payment Details * Want to pay now ? Click here
 


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(Order ID if paid by Credit Card / T.T. details / Cheque Number / Cheque Date / Bank name / Bank Branch etc.)
10 Varification Code
 
 
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  Contact Information
   
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Permanant Address :

Alopecia Treatment Center

(Formerly known as Herbal Treatment Center)

Dr. Rohit Shah
1/3839 Nani Desai Pole, Nr. Maltiben's Hospital, Soni Falia, SURAT-395003. (Gujarat) INDIA.
Consulting Time: 1 pm to 6 pm (Indian standard time)
Telephone : +91-261-2591146.
Mumbai Address :
Crresshhha Polyclinc
(2nd and 4th Sunday of the month)

Devi Ekveera 'A' Building (Basement), Nr. HDFC, 79, Old Nagardas Road, Andheri (E), Mumbai - 400 069.

Consulting Time: 11 pm to 4:30 pm
Ph.:022-66989770
Schedule 2008
March 9, 23
April 27, (not availalbe on 13)
May 11, 25
June 8, 22
Ahmedabad Address :

Abhishek Hospital
(Every First Sunday of the month)

C/o. Dr. Hitesh Shah / Dr. Rita Shah,
Bhagavati Complex, Jain Merchant, Nr. Mahalakshmi Char Rasta, Paldi, Ahmedabad.
Consulting Time: 12 pm to 5 pm
Ph.:079-26633633
Schedule 2008
March 2
April 6
May 4
June 1
     

E-mail:

 rohit@alopeciacure.com
Alternative Email: alopeciacure@hotmail.com (will be checked weekly)
 

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