Please fill this form for Thalassemia Minor (trait) Screening Name Title - Select -MissMsMrMrsDrOther... Enter other... First Name Last Name Father's Name / Husband's Name Date of Birth Gender Male Female Others Nationality Indian Non-Indian Marital Status Married Unmarried Religion - Select -HinduismChristianityIslamSikhismJainismBuddhismOthers Community - Select -SindhisPunjabisGujaratisMarwardisBengalisSaraswatsGaursOthers Residential Address Pin Code Telephone Number Mobile Number Email ID Occupation History of Thalassemia in Family Yes No History of blood transfusion Yes No Marriage among cousins Yes No Would like to receive report through Email Whatsapp Courier Self collection Note: - Above mention information is for the purpose of analysis only and will be kept confidential. - In case of “Positive” result for Thalassemia minor, all the members of the family need to be tested for Thalassemia. - The report of this test will not be valid for any medico legal case. I agree to the terms of service. ConsentI have come to know the basic knowledge of Thalassemia through counselling, IEC (information by electronics and communication) material supplied by Indian Red Cross Society (NHQ), New Delhi. I have been also informed that the blood sample shall be collected only for Thalassemia screening What code is in the image? Enter the characters shown in the image.
