As Patient

    Patient Personal Details

    Date of Joining:
    Your Name:*
    Middle Name:*
    Last Name:*
    Gender:*
    Date of Birth:*
    Marital Status:*
    State:* City:* Pincode:*
    Residential Address:*
    Mobile:* WhatsApp:* Email Address:*
    Education Qualification:*
    Occupation:*
    Type of Ataxia:*
    Year of Diagnosis:*
    Confirmation of type of ataxia through genetic testing:*
    Name of Testing Laboratory:
    Under treatment of:

    Care Taker Detail

    First Name:*
    Middle Name:*
    Last Name:*
    Relation with You:*
    Gender:*
    Marital Status:*
    Mobile:*
    WhatsApp:*
    Email Address:*
    Education:
    Ocupation:*