06 Sep 2010

Support Center » Submit a Ticket » Assessment

Submit a Ticket If you can't find a solution to your problems in our knowledgebase, you can fill in the fields below with as much detailed information as possible and send it to our support personnel. General Information Full Name: * Email: * Priority: Low Medium High Urgent Emergency Critical Assessment request Age: * Sex: * Female Male Race: * White Black Brown Yellow Country: * When did it start ?: * Detail of affected parts?: * Biggest area (size/ location): * Smallest area (size/ location): Is any of these affected?: Lips Finger Tips Genitalia What about hair in affected areas?: * Hair have pigment Pigment is reduced/ some hair have pigment No hair have pigment No hair in affected area History of re-pigmentation: No Yes, spontaneous Yes, with treatment Family history details (specify Grand Parents, Siblings etc): Who made the diagnosis?: * Self Primary physician Dermatologiest Basis of diagnosis: * Visual examination Clinical history Skin biopsy Have pregnancies affected your disease?: Not applicable Improved Worsened No change Family history: No Yes How has your vitiligo behaved in last six months?: No change Progressive Improving Spreading in some area's and repigmenting in other Summary of any co-existing chronic disease?: Message Details Subject: *  Loading Knowledgebase Suggestions... Upload File(s) Verify Submission Please enter the text you see in the image at the right into the textbox below. This is required to prevent automated submission of Tickets.  Back  Login [Lost Password]  Email: Password: Remember Me:    Search -- Entire Support Site -- Knowledgebase Downloads Troubleshooter

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