Skin and Hair Problem

Online Consultation

Please fill the below form, provide detailed information on existing medical condition, past medical history, current/past medications and attach available scan reports and pictures preferably high quality images as it would help our physicians to examine your ailment(s) with more clarity.

(Step 1 of 4) Basic Information


New / Old Patient

(Step 2 of 4) Let us know about your skin problems and duration of the condition


Itching
Pain

(Step 3 of 4) Let us know about your hair problems and duration of the condition


Do you have patchy hair loss?
Do you have dandruff?
Do you have hair breakage / split ends?
Any Significant illness in the Past one Year
Do you have anaemia (Low Haemoglobin)?
Do you have a Thyroid Disorder?
Have you lost significant weight in the past one year?
Do you work night shifts?

(Step 4 of 4) Co-existing medical, surgical conditions / attach relevant images, documents

Co Existing Medical / Surgical Conditions

Current medications / Previous treatment details
Please provide high quality pictures as it would help our physicians to examine your ailment(s) with more clarity.
(Please upload maximum of 1MB files only, all inclusive.)
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(Please upload maximum of 1MB files only, all inclusive.)
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(Please upload maximum of 1MB files only, all inclusive.)
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(Please upload maximum of 1MB files only, all inclusive.)