IndoUSrare Patient Contact Form Thank you for your interest in seeking information assistance from IndoUSrare. Please provide the following information to help us understand your current situation. Required* Full Name * Please enter your full name Your email address * An email address where we can contact you at. We will not share your contact info with anyone. Phone number Please enter your phone number with area code, if applicable. We will not share your contact info with anyone. Location * City / State where you live Your physician / hospital* Name of physician & hospital are you current seeking treatments for this disease. Include city/state of the hospital [cf7mls_step cf7mls_step-1 "next" ""] IndoUSrare Patient Contact Form Required* About the disease Tell us about the disease to help us understand patients better. Enter N/A if you don't know answers to any question. Name of the disease * Genetic details of disease (optional) Mention the name of the gene involved, any other genetic/scientific details as much as you know Symptoms (optional) History of diagnosis (optional) How are patients generally diagnosed? How many months/years into life do they get the diagnosis? Any other information pertaining to diagnosis. Current Treatments (optional) How are patients treated for this disease today? Include allopathic medicines, aryurvedic medicines, home remedies, and other activities to manage symptoms commonly used by patients Prospective Treatments (optional) Describe any prospective treatments being developed for this disease. Include their development status, trials status, country where it is currently being developed etc [cf7mls_step cf7mls_step-2 "Back" "Next" "Step 2"] IndoUSrare Patient Contact Form Thank you for your interest in joining IndoUSrare as a member. Please complete this form to initiate membership Name of the disease * Genetic details of disease (optional) Mention the name of the gene involved, any other genetic/scientific details as much as you know Symptoms (optional) History of diagnosis (optional) How are patients generally diagnosed? How many months/years into life do they get the diagnosis? Any other information pertaining to diagnosis. Current Treatments (optional) How are patients treated for this disease today? Include allopathic medicines, aryurvedic medicines, home remedies, and other activities to manage symptoms commonly used by patients Prospective Treatments (optional) Describe any prospective treatments being developed for this disease. Include their development status, trials status, country where it is currently being developed etc [cf7mls_step cf7mls_step-3 "Back" "Step 3"]