DoctorSelect DoctorDr. Nitin BardeDr. Radhika Barde
SpecialitySelect SpecialityHair TransplantHair Treatment
First Name
Middle Name
Last Name
Date of Birth
GenderSelect GenderMaleFemaleOther
Address
City
Mobile No.
Email
Marital StatusMarriedUnmarried
Name of Spouse
Occupation
For how long have you been suffering from hair loss(in Months)?
Is it continuous or intermittent?ContinuousIntermittent
How much hair do you lose per day?
Do you have any skin allergy?
How are you presently dealing with your hair loss?(Current Treatment)OilShampooSolutionTabletsAyurvedicHomeopathyNone
Do you Suffer from any of the skin disorder?PsoriasisDandruffItchingNone
Family History who suffered hair loss?FatherBrotherUncle (Paternal)Grandfather (Paternal)MotherSisterUncle (Maternal)Grandfather (Maternal)Other
What do you think has caused your hair loss?
How come you got to know about us?WebsiteRelativesNewspaperInternetJustdialFriendsOthersFacebook
WhatsApp us
