Registration Forms

Free Registration Form for New Patient

1 General Information * Field is mandatory!

Name* :  Age* :  Gender* : Male Female

Address* :

City* :  State* :  Zipcode* :

Country* :

Tel.* :  Alternate Tel.* :

Email* :  Alternate 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 Description of your problem in your words

3 Which type of hair problem do you suffer? Skip this if you don’t know about your hair problem   Click here to see different types of hair problems www.sanjivnikaya.com

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 etc   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. If the hair loss is visible then pictures are helpful to make the diagnosis and preparing products.     2. If your internet connection speed is too slow, then don't attach the picture now. Send the pictures later, once registration is completed.     3. 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 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       *If you have attached the pictures, registration process may take few seconds.

Note :

• 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 and conditions