Questionnaire about Vitiligo

Online Email Consultation: In order for our herbal medicine practioner to have a clear picture of your situation, please fill out the short questionnaire below. If possible, attach photo(s) of the affected area at the bottom of this form. After you have submitted the form, it will be sent directly to Dr. Li for her review. Please allow 1-2 business days for a response.**

Your name:
Patient Name (if different)
Your Email Address: (Required)
Verify Email Address: (Required)

Sex:
Age:
Race:

Weight:

Occupation:

How many years have you had Vitiligo?

Which part of your body does the Vitiligo affect?

How Serious do you think your Vitiligo is?

Do you have any family member who has Vitiligo?

Do your white spots keep spreading?

Have you tried any alternative treatment?


How did you hear about us?


Please Specify:
(such as Google, WebMD, etc..)

Please add any comments and questions you have below:

You may attach (optional) Pictures to help Dr. Li understand the situation:

Image1:

Image2:

Any personal information you submit to us is strictly confidential. Please take a look at our privacy policy to learn more.


**Even though we have herbal Doctors ready to answer your questions, we can not provide medical advise on-line. Your medical doctor who knows your clinical history is the only person qualified to give you medical advise. We can only guide your use of our product and let you know how our product may be able to benefit your personal case.

Telephone: 1-888-880-1499
(within USA, CA) * 1-650-588-8335

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