Let's get to know you! ^*

Please provide your correct phone number and email so our Doctor can call you for free consultation!

Name ^*

Age ^*

Email ^*

Phone number ^*

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Date of Birth ^*

Let’s settle the age-old mystery—when’s your birthday?

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Gender

Male

Female

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How would you describe pattern of your hair loss? ^*

Where are you noticing changes to your hair?

Grade 1

Grade 2

Grade 3

Grade 4

Grade 5

Grade 6

Heavy Random Hair loss

Bald Patches

Other

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Where are you noticing more hair loss?

At the front hair line only

At top only

At both area

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How long has this issue been bothering you? ^*

You’re not alone—1 in 3 male and 1 in female in India experiences the same issue.

< 1 Month

1 - 3 Months

> 3 Months

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Have you noticed any changes in your hair texture, such as thinning or increased brittleness? ^*

There’s no need to worry—nobody is perfect!

Yes

No

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Are you experiencing any scalp irritation, itching, flakiness, or tenderness? ^*

Yes

No

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Have you tried any medication or any product for hair loss?

Let’s find what works best for you!

/

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Do you have a family history of hair loss or baldness (on either side of your family)? ^*

Lets who is responsible for you hair loss.

Yes

No

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Do you have any medical conditions (e.g., thyroid problems, diabetes, anemia) that might contribute to hair loss? ^*

You never know what's causing hair loss.

Yes

No

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Are you currently taking any other medication?

Let’s make sure our medication works well together!

/

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Let's closely look at your hair loss problem.

Upload 2-3 clear picture of your bald spot or where your noticing your hair lose.

You can drag & drop or paste as well

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