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| E-Mail |
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| Password |
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| Confirm
Password |
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| Phone
No |
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| Name |
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| Address1 |
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| Address2 |
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| City |
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Code/zip code |
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| Description(associated
Symptoms like weakness,fever,diarrhea etc.,) |
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Weight
(Example 50kgs or 50lbs) |
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| since
how long |
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| Natur
& Type of Work |
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Period
of Treatment So Far
(Example: 1 Year) |
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| Probable
mode of Transmition |
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| Post
Date |
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