Alopecia Treatment Center dr rohit shah herbal tricologist
     
Common Types Of Alopecia   Useful Ayurveda Herbs

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Home » Start the treatment now » New Registration Form  
   
 
New Patient Registration Form
* Field are mandatory !
 
1 General information
 
Name * Age *
Sex * Male Female
Address *
  (Type the correct address where your products to be sent)
Country *
Tel. * Alternative Tel.
E-mail * Alternative E-mail
2 Select the support center name if you have already consulted OR you want to consult
 
Support Centers in India Support Centers Abroad
1 Dr. Rohit Shah Surat (H.O.)
5 Dr. Heena Quraishi Mumbai
6 Dr Sunil Shah Ahmedabad
7 Dr. Meenu Gandhi Haryana
3 Holly McGuffin USA
4 Mrs. Patel UK
8 Dr Akshay Banker Canada
9 Spela Seme Europe
3 Description of your problem in your words
 
4
Which type of alopecia do you suffer ? skip this if you don't know the type of hair loss or
click on the photographs to see different types of alopecia.
 
Alopecia areata Alopecia areata   Tellogen Effluvium Tellogen Effluvium
Alopecia totalis / universalis Alopecia totalis / universalis   Chronic Tellogen Effluvium Chronic Tellogen Effluvium
Male pattern baldness Male pattern baldness   Scaring alopecia Scaring alopecia
Female pattern baldness Female pattern baldness   Chemotherapy and hair loss Chemotherapy and hair loss
Diffuse alopecia Diffuse alopecia   Beauty Treatment and Hair loss
hair dye, hair colour, perming, straightening ect
Beauty Treatment and Hair loss - hair dye, hair colour, perming, straightening ect
Traction alopecia Traction alopecia   General hair loss  
Trichotillomania Trichotillomania   Others  
 
5 Do you suffer any other medical conditions like thyroid, diabetes, hypertension, depression, stress, Irregular menstruation cycle, constipation, anemia etc describe here...
 
6 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)
 
7 Quality of your hair
 
Normal Oily Brittle Thin
Rough and Dull Dry Blond Wavy
8 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 send the pictures now, please send it later to info@alopeciacure.com (with Patient ID)
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. Picture No. Picture No.
9 Payment Details * (if you have already paid to any of our support center or online payment)
 
Give the payment details (If you have already paid)
OR   I will pay later
10 Varification Code ( * This is mandatory. This will help us to prevent automated registrations)
 
Enter the code shown
The code is case sensitive.
 


Notes
If your form is submitted successfully then you will get a message that your details submitted successfully and you will also get a patient id on your email address. This registration id is necessary for making payment and any further communication. If you do not get your patient id then please submit your details again.
If you are not able to send online form click here to download the consultation form in MS Word format .
Please read the Agreement.
 
 
 

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Results
Before   After
Before   Before
more results...
 
Frequently asked questions
I am interested in treatment
what should i do ?
What is the cost of the treatment ?
How can I pay ?
 
Contact Information
Alopecia Treatment Center

Surat (H.O.)

Dr. Rohit Shah   Ragini Shah
  Dr. Rohit Shah   Ragini Shah
H. O. Address Tel. / Email Time Schedule
Alopecia Treatment Center
( Formerly known as Herbal Treatment Center )
1/3839 Nani Desai Pole, Nr. Maltiben's Hospital, Soni Falia, SURAT-395003. (Gujarat) INDIA.
(C) +91-261-2591146
Email : rohit@alopeciacure.com
1 pm to 6 pm (IST)

Support Centers

USA
UK
Canada
Europe
Mumbai
Ahmedabad
Haryana

Support Center : Surat (H.O.)

  Support Center Address Tel. Time Schedule  
Dr. Rohit Shah
Dr. Rohit Shah

Alopecia Treatment Center
Formerly known as Herbal Treatment Center
1/3839 Nani Desai Pole, Nr. Maltiben's Hospital, Soni Falia, SURAT-395003. (Gujarat) INDIA.
Email: rohit@alopeciacure.com
For prior appointment: +91-261-2591146 1 pm to 6 pm (IST)

Support Center : USA

  Support Center Address Tel. Time Schedule  
Holly McGuffin
Holly McGuffin
Hair and Scalp specialist
[ Trichologist ]

Certified Logo

HOLLY MCGUFFIN will not available from Jan. 26-31st

Bikram's Yoga College of India, Detroit-Metro
122 Main Center Northville
MI 48167

Phone consultation: $50

Personal consultation: $100

personal consultation is Strictly by prior appointments...
For appointments.. Call at 248-719-1972 [8-10 am]


Email: holly@alopeciacure.com
For prior appointment: (248) 719-1972 Preferable time to call
8.00 am to 10.00 am

[7 days a week, subject to availability]

Support Center : UK

  Support Center Address Tel. Time Schedule  
Mrs. Patel
Mrs. Patel

Kingbury, London. For prior appointment: 0 773 875 2454 Preferable time to call
7.00 pm to 10.00 pm
7.00 pm to 10.00 pm

Support Center : Canada

  Support Center Address Tel. Time Schedule  
Dr Akshay Banker
Dr Akshay Banker

93 Dundas St. E., [above Dollarama], Suite # 107, Mississauga, ON. L5A 1W7.

[Intersection of Hurontario and Dundas]

Availability #  all 7 days with prior appointment

Personal consultation: CA$100

Phone consultation: CA$50

For prior appointment: +1 6477733074
+1 6478684340
11am to 1pm & 4pm to 6pm
monday to saturday

Support Center : Europe

  Support Center Address Tel. Time Schedule  
Spela Seme
Spela Seme

Hair Genesis Studio
Komenskega 1, 4000 Kranj, Slovenia, EU

Personal consultation: 80 Eur.
[It is strictly by prior appointments]

Phone consultation : 60 Eur.
preferable to book phone consultation is via email


Email: spela@alopeciacure.com
For prior appointment:
00386 31 444868
10 am to 6 pm
7 days a week [subject to availability]

Support Center : Mumbai

  Support Center Address Tel. Time Schedule  
Dr. Heena Quraishi
Dr. Heena Quraishi
BHMS, MD. Alt
09821508615
call between 11 am to 1 pm
Crresshhha Polyclinc
Devi Ekveera A Building [basement], beside HDFC home loan, Opp. Saraswat bank, below Sneh Nursing Home, 79,Old Nagardas Road, Andheri [E], Mumbai - 400 069.
Help Line No.
098219 41416 Ms. Vaisali
For prior appointment: 022-66989770 7.30pm to 9.30pm
Dr. Rohit's Mumbai Schedule
Dr Rohit himself will visit this centre
every 2nd and 4th Sunday of the month
[time ]
Ph.022-66989770 (For prior appointment)
2nd Sunday of every month 4th Sunday of every month
2012-Feb-12
2012-Mar-11
2012-Apr-08
2012-Feb-26
2012-Mar-25
2012-Apr-22

Support Center : Ahmedabad

  Support Center Address Tel. Time Schedule  
Dr Sunil Shah
Dr Sunil Shah
[M.D.]
Dr Sunil [amdavad branch] is not available on 1st January
Alopecia Treatment Center
14/10 Vir-vijay Society, Near Sanghavi High School, Naranpura, Ahmedabad.
For prior appointment: 079-27410607
079-27417788
Preferable time to call
6 pm to 8 pm
6 pm to 8 pm
Dr. Rohit's Ahmedabad Schedule
Dr Rohit himself will visit this centre
every 1st Sunday of the month
[time 6 pm to 8 pm ]
Ph.079-27410607
079-27417788 (For prior appointment)
1st Sunday of every month
2012-Feb-05
2012-Mar-04
2012-Apr-01

Support Center : Haryana

  Support Center Address Tel. Time Schedule  
Dr. Meenu Gandhi
Dr. Meenu Gandhi
MD ( Skin & VD)
Dept. of Dermatology (Mahabir Dal Hospital)
Kunjpura Road, Karnal, Haryana.

(Residence)296 Sector 14 urban estate Karnal.
For prior appointment: 9996629614 Preferable time to call
10am to 2 pm (IST)
9.30am - 1.30pm (IST)
5.00pm - 6.00pm (Residence)
Mom - Tue - Wed - Fri - Sat
 
 
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