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Cancer Patient

Registration Form for Cancer Patients

Please fill the form below with accurate data and submit to us to get aid in treatment.

Guidelines for filling up of Form

*Your working mobile no. is required. Doctor will contact you at this phone.

*Upload all your diagnosis reports in a single pdf file. The file size should not be more than 3 MB.

*First Name *Last Name

*Valid Mobile No.

Email ID

*City/District *State *Country

*Gender

*Age

# Cancer Type Select
1 Breast
2 Cervix
3 Blood
4 Liver
5 Kidney
6 Food Pipe
7 Oral
8 Prostate
9 Bone
10 Uterus
11 Colon
12 Pancreas
13 Intestine  
14 If Other

Condition

Pain

Any other detail

*Reports (8kb to 3MB)(JPG,PNG,GIF,PDF)

Your commitment and support Can save many lives in India by organize “Early Cancer Detection & Awareness Camps”.

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Kulwant Singh Dhaliwal

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WORLD CANCER CARE

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