Patient Registration

Name of Patient
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Date of Birth
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Sex
MaleFemale
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SMA Type
Type1Type2Type3Type4
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*
Do you have Genetic Test Report
YesNo
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*
Please upload the Genetic Test Report
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*
Ambulatory/non-ambulatory (Walking abilities)
Can walkCan standCan sitCan't sit
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*
Non-invasive ventilation (BiPAP) dependency
YesNo
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*
Invasive ventilation (Tracheostomy) dependency
YesNo
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*
Feeding tube (G-tube/NG-tube) dependency
YesNo
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*
Scoliosis surgery
YesNo
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Other deformities
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Treating Doctor Name
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Hospital Name
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Patient Education/Occupation
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Name of Parent/Guardian
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Name of Father/Mother/Guardian
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Contact No
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Maximum 10 characters allowed.
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*
Address
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*
City of Residence
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*
Pin Code
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*
Email Address
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Password
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    Strength: Very Weak
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    Help?
    I Agree
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    Acceptance of 'Hold Harmless declaration'
    I hereby declare and authorise CureSMA India and its members to share information provided by me to any institution, agency, company, hospital or clinical organisation for the purpose of providing patient information to any of the above institutions/organisations. I do not have any objections to share this information that has been provided above by me to CureSMA India. The information shared by me includes but not limited to - patient information, images, videos, contact details and/or any clinical data. This authorisation is not conditional under any circumstances. My acceptance of this 'Hold Harmless declaration' should be treated as a consent to indemnify CureSMA India from any liability (legal, commercial or penal) arising out of the sharing of the information that has been provided by myself.
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