IndoUSrare Patient Contact Form

    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.

    An email address where we can contact you at. We will not share your contact info with anyone.

    Please enter your phone number with area code, if applicable. We will not share your contact info with anyone.

    City / State where you live

    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

    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.

    Mention the name of the gene involved, any other genetic/scientific details as much as you know

    How are patients generally diagnosed? How many months/years into life do they get the diagnosis? Any other information pertaining to diagnosis.

    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

    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

    Your Needs

    Explain your expectation from therapy, IndoUSrare and the rare disease community at large

    Describe your needs from a prospective treatment.

    Briefly explain your expectation from IndoUSrare. It will help us align our services to your requriements.

    [cf7mls_step cf7mls_step-3 "Back" "Step 3"]