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MindHeal
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MindHeal
 
Step 1. Preliminary Data

To get started, fill out the following personal details about yourself:


Full Name:

      
 
Age:

      
 
Sex:

        Male      Female
 
Postal Address (for dispatch of medicines):






      
 
Phone:

      
 
E-mail:

      
 
Alternate E-mail:

      
 
Preferred Language:

        English     Hindi     Marathi   
 
Description of disease:






      
 
Diagnosis (if any):






      
 
Photograph (attach here):

      
 
     



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