Follow Up Treatment

1 General Information * Field is mandatory!

Name* :  Age* :  Gender* : Male Female

Address* :  (Type the correct address where your products to be sent)

City* :

Country* :

Tel.* :

Email* :

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

2 Mention your patient ID & name of the branch where you registered first.

Patient Id :   Doctor & Branch Name: Branch & Doctor (This is what you had received when you submited your detail first time. If you don't remember please leave it blank)   (Select the support center or name of the doctor, where you registered first time.)

3 What changes did you notice after staring herbal treatment ? describe in your words.

4 Attach the latest picture of affected area after starting herbal treatment

1. (the File size should not be more than 300 KB, File format should be .jpg, .gif, .tif, .png, .pcx or .bmp only)     2. If you are not able to send the picture with this form please send it to rohit@alopeciacure.com, with your Patient Id (Inquiry ID) .

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

OR I shall pay later

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

Enter the code shown        The code is case sensitive

Note :

• Treatment package is specially designed according to country weather.     • Abroad Indian patients are requested not to apply for Indian products but apply for the group of the country where they belong to.     • Product will be send by Courier / Speed Post.     • Online Tracking is only available if provided by Courier / Post / AirMail.     • Approximate time to receive the products. For abroad patients 17-20 days ( depending upon the country).     • Approximate time to receive the products. For Indian patients 7-10 days.     • Product will be couriered after realization of Payment.