Membership Form

 

 

Thalassemics India ( regd. )

A-9, Nizamuddin West, New Delhi-110013
Tel: 41827334, 46595811
Email: thalcind@yahoo.co.in


REGISTRATION FORM

Parent/Guardian's Name :    
Religion :  
Address ( R ) :  
Address ( O ) :  
Email :  
Telephone(R) :  
Telephone(O) :  
Mobile No. :  
Occupation :  
Name of Your Thalassemia Child :  
Date of birth :  
Sex :  
Blood Group :  
Blood transfused at :  
Name of the treating Doctor :  
Status of HBV, HIV & HCV :