Patient registration - Indian Association of Muscular Dystrophy (IAMD)

Please provide information regarding the affecting individual (yourself or your child)

Name *

First

Last

Date of Birth *

Email and Phone

Email *

Phone *

Permanent address *

Address Line 1

City

State / Province / Region

Postal Code

Country

ID card

Citizenship *

Type of Muscular Dystrophy *

Please identify the type of Muscular Dystrophy you have if you have been diagnosed.

If you don’t know what type of Muscular dystrophy you have, select “I don’t know”

If you have some other condition, please select “Other”

What is your present condition?

Relative relationship and name

Relationship *

Name *

First

Last

Relative phone and email

Phone *

Email *