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Home >> Consultation Form

Conultation Form

Name:
Age:
Gender:
Address:
Country:
Landline No.:
Mobile No.:
E-mail ID:
Fax No.:
History of Present Disease:
Onset: when did the problem start/ duration
Sites of involvement/ Areas affected:
Symptoms: eg. itching/ pain /redness/ rashes:
Progression of disease (Has the nature of symptoms changed?):
Provocative factors: Heat, cold, sunlight, exercise, drug ingestion:
Any seasonal change or day /night variation:
Treatment history & response to it:
Past/Concomitant Medical History:
Allergy (to drugs or anything else):
Any other problem like diabetes or hypertension:
Medical history/ Any chronic medicinal intake:
Habits (smoking, alcohol or drug abuse):
Family History:
History of any similar illness in family members:
History of any other significant problems e.g. asthma, rhinitis:
*Kindly attach a few close up photographs of your problem area and e-mail to: info@satyaskinhair.com*

Consultancy Charges

Consultancy for India:	Rs. 500/-
Consultancy for Outside India:	$100.00

CONSULTATION CHARGES:

Rs. 500/- for each consult for patients from India or US $ 100/- for patients outside India.

You have to pay by depositing the amount in the bank account (details of which are given below).

A valid one time use prescription will be sent by email/ courier. If you also require the medicines then please authorize the DHL courier for the same & you will have to pay only the actual medicine cost.

Account Number : 307402010554682
Banker's Name : UNION BANK OF INDIA
Branch : SUBJI MANDI BRANCH, 44-A KAMLA NAGAR, DELHI-110007.
IFS code: UBI NO530743