Alopecia Treatment Center
Dr Rohit Shah visits Andheri (East) Mumbai every 2nd and 4th Sunday of the month. click here for more information.
 
Dr. Rohit's Natural Remedies For Alopecia
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Home » Start the treatment now » New Registration Form  
   
 
Free Registration Form for New Patient
 
1
General information
* Field are mandatory !
 
Name *
Please enter your name
Age *
Please enter your age
  
Gender * Male Female

Please select your gender
Add. *
Please enter your address
     
City
State
Zipcode  
Country * Select your country from list
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Tel. *
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Alternative Tel.
E-mail *
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Alternative E-mail

Email Id is very important for future communication, please be careful while typing email id and make sure that you typed it correctly.

2 Description of your problem in your words
 
3
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      
4 Do you suffer any other medical conditions ? like thyroid, diabetes, hypertension, depression, stress, Irregular menstruation cycle, constipation, anemia etc describe here...
 
5 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)
 
6 Quality of your hair
 
Normal Oily Brittle Thin
Rough and Dull Dry Blond Wavy
7 Attach the Pictures of only affected area. Each picture file size should not be greater than 3MB.
 
1.
2.
3.
If the hair loss is visible then pictures are helpful to make the diagnosis and preparing products.
If your internet connection speed is too slow, then don't attach the picture now. Send the pictures later, once registration is completed.
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.
8
Do you want to schedule skype live consultation with Dr. Rohit Shah ?
(Dr. Rohit Shah is founder of Alopecia Treatment Center)
 
Dr rohit shah
Dr. Rohit Shah

For Indian patients: INR 2000 for 15 minutes. For abroad patients: USD 200 for 30 minutes

  Yes. I am interested.

  No. Not at this stage.

* Conferencing time will be given once we received consultation fee. *Preferred languages English or HIndi.

9 Payment Details (If you have already paid to any of our support center or online payment)
 
Give the payment details
OR   I shall pay later
10 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 idon 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.
 
 
 
Video and Testimonials
 
clinic locator
 
Holly McGuffin, USA

Inspiring Journey
with
alopecia areata...

Trichologist
Holly McGuffin,
 

My 7 amazing days in India, to learn more about different types
of Alopecia

Dr. Sacha Piedallu
 
 
Our Quick Links
Frequently Asked Questions
Want to start the treatment ?
Want to place an order for Follow up treatment ?
What exactly in the treatment ?
Want to know the opinion of our expert doctor for your problem ?
Cost and payment
Have already paid but do not receive the product ?
Having a query during the treatment
Want to know about nearest branch?
Want to send an E-mail ?
 
 
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 (Formerly known as Herbal Treatment Center)

 

  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
Dr Rohit Shah   Ragini Shah
     Head Office :
  Head Office Dr. Rohit Shah   Dr. Rohit Shah
     International Support Centers :
  USA Trichologist  Holly McGuffin   Trichologist Holly McGuffin
  Canada Akshay Banker   Akshay Banker
  UK Mrs. Bhavna Patel   Mrs. Bhavna Patel
  Singapore Dr Maitri Nagar   Dr Maitri Nagar
  Hong Kong Veena Dansingani   Veena Dansingani
  Malaysia Shirley Lai   Shirley Lai
  South Africa Dr. Sacha Piedallu   Dr. Sacha Piedallu
     India Support Centers :
  Ahmedabad Dr Sunil Shah   Dr Sunil Shah
  Valsad Dr. Sahil Masalia   Dr. Sahil Masalia
  Navsari Dr. Sahil Masalia   Dr. Sahil Masalia
  Vapi Dr. Sahil Masalia   Dr. Sahil Masalia
  Vadodara Dr. Bharat shah   Dr. Bharat shah
  Gandhidham Dr. Ashok D. Thakkar   Dr. Ashok D. Thakkar
  Ankleshwar Dr.K.H.Vekaria   Dr.K.H.Vekaria
  Mumbai Dr. Heena Quraishi   Dr. Heena Quraishi
  Mumbai Dr. Niti Shah   Dr. Niti Shah
  Sangli Dr.Sonali Bapat   Dr.Sonali Bapat
  Pune Dr Karuna Soni   Dr Karuna Soni
  Pune Dr. Sunita Chaudhari   Dr. Sunita Chaudhari
  Pune Dr Mahesh Bora   Dr Mahesh Bora
  Pune Dr Kinjal Sukhadia   Dr Kinjal Sukhadia
  Nasik Dr Shailesh Londhe   Dr Shailesh Londhe
  Indore Dr. Sanjay Kucheria   Dr. Sanjay Kucheria
  New Delhi Dr Dipti Nagar   Dr Dipti Nagar
  Kolkatta Dr Poonam Shukla   Dr Poonam Shukla
  Hyderabad Dr  Annam Agnishikha   Dr Annam Agnishikha
  Jaipur Dr. Fiyonika Porwal   Dr. Fiyonika Porwal
  Bangalore Merlin Subhashini   Merlin Subhashini
  Bhubaneswar Dr Annada Prasad Dash   Dr Annada Prasad Dash
  Rourkela Dr Annada Prasad Dash   Dr Annada Prasad Dash
  Karnal Dr. Meenu Gandhi   Dr. Meenu Gandhi
  Gurgaon Dr Sonal  (Garg) Agarwal   Dr Sonal (Garg) Agarwal
 
 

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Types of Alopecia
Alopecia Areata
Scarring Alopecia
Male pattern baldness
Female pattern baldness
Telogen effluvium
Tricotilomania
Traction Alopecia
Chemotherapy and Hair Loss
Home Remedy Tips
Hairloss due to anemia
Hairloss (any type)
Hairloss due to color and dye
Premature graying of hair
Pattern Baldness
Dandruff
Lusterless, dull hair
Menopause and Hairloss
Pediculosis
Ultimate haircare tips
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