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New Patient Registration Form

General information

* Field are mandatory !

Name *

Age *

Gender *

Male

Female

Add. *
	Type the complete address with city, state and zip code

Country *

Tel. *

Alternative Tel.

E-mail *

Alternative E-mail

Description of your problem in your words

Which type of alopecia do you suffer ?

skip this if you don't know the type of hair loss or
click here to see different types of alopecia.

Male pattern baldness	Female pattern baldness	Diffuse unpattern alopecia
Alopecia areata	Alopecia totalis / universalis	Scaring alopecia
Tellogen Effluvium	Chronic Tellogen Effluvium	Chemotherapy and hair loss
Traction alopecia	Trichotillomania	Beauty Treatment and Hair loss hair dye, hair colour, perming, straightening ect
General hair loss	Others

Do you suffer any other medical conditions like thyroid, diabetes, hypertension, depression, stress, Irregular menstruation cycle, constipation, anemia etc describe here...

Describe if you have done any lab reports like Thyroid, female hormones, DHT, serum, ferritin, any type of biopsy report etc. (skip this if you have not done any lab reports)

Quality of your hair

	Normal		Oily		Brittle		Thin
	Rough and Dull		Dry		Blond		Wavy

Attach the Pictures of the affected area

1.
2.
3.

•	If the hair loss is visible then pictures are helpful to make the diagnosis and preparing products.
•	If you are not able to submit the pictures now, please send it later to info@alopeciacure.com
•	If you don't want to send the pictures, please see the page "Types of alopecia" and mention the picture no. similar to your problem.

Picture No.

Payment Details * (if you have already paid to any of our support center or online payment)

Give the payment details

I shall pay later

Dr Rohit will be in UK, Netherland, Switzerland, Germany, Italy, France.
(from 5th May to 24th May 2013) Click here for entire schedule.

Yes, I would like to consult when he visits my country.

* We will send you an email for confirmation of the appointment.

Security Code ( * This is mandatory. This will help us to prevent automated registrations)

	Enter the code shown
	The code is case sensitive.

Notes

Registration is completely free. If your registration form is submitted successfully then you will get a confirmation message with patient id on your registered email address.If you do not receive your patient id then please submit your details again.
Patient id is necessary for any future communication,sending picture files, placing an order or follow up treatment.
After receiving your details, the team of our expert doctors will give their opinion within 3-7 days.
If you are not able to send online form click here to download the consultation form in MS Word format .
By submitting this form you are agreed to our terms and conditions.

Dr Rohit will be in UK, Netherland, Switzerland, Germany, Italy, France. (from 5th May to 24th May 2013)

Click here for entire schedule.

If you want to meet Dr. Rohit,

Click here for registation

USA Support Center

	Inspiring Journey with alopecia areata...
Trichologist Holly McGuffin,	More details »

Europe Support Center

	How alopecia made them travel to India from Europe...
Dr Spela and Robin	More details »

South Africa Support Center

	My 7 amazing days in India, to learn more about different types of Alopecia
Dr. Sacha Piedallu	More details »

Before Treatment		After Treatment

Dr. Rohit Shah on Colors TV

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Frequently Asked Questions

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International Conference

Dr. Rohit Shah, in International Conference and Exhibition on Cosmetology & Cosmetics, which was held in November 23-24, 2012 Hyderabad, India. The conference was arranged by OMICS Group.Dr. Rohit explained how Ayurveda Herbal Treatment is safe and potential way to cope up with Alopecia Areata.

Articles

Unpredictable And Capricious Alopecia Areata (Dr. Rohits Article in Health and Nutrition )

Know more

Hair loss treatment

Contact Information : Head Office

Alopecia Treatment Center
1/3839 Nani Desai Pole,
Nr. Maltiben's Hospital,
Soni Falia, Surat - 395003.
(Gujarat) India.

Phone	:	+91-261-2591146
Time	:	1 pm to 6 pm (IST)
Email	:	rohit@alopeciacure.com


Dr Rohit Shah		Ragini Shah

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