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Cheyutha Thalassemia Registration Form
Name
*
Age
*
Gender
*
--Select Gender--
MALE
FEMALE
Blood Group
*
--Select Blood Group--
A+
A-
A1+
A1-
A1B+
A1B-
A2+
A2-
A2B+
A2B-
AB+
AB-
B+
B-
Bombay Blood Group
O+
O-
White Card
*
--Select Type--
Yes
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Choose Place
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--Select Place--
GGH
Red Cross
Mobile
*
Enter valid number!
District
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--Select District--
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City
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--Select Near City--
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Amalapuram
Kakinada
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Address
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