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PATIENT REGISTRY
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Kindly request to fill all the columns for data to be stored successfully, if not applicable put a - or write NA in the given space below.
Patient's Name
Mother's name
Father's name
Date of birth of patient:
enter in the format YYYY-MM-DD
age of patient:
present weight of patient:
Email address
Phone number
address
city
state
country
Pin code
Any Doctor treating the patient?
Name of hospital
ERT status
ERT Start Date
Diagnosed Age
Any Symptoms?
Any medical challemges faced?
Any other information you would like to disclose?
Submit
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