Thyroid Screening Registration Form – Princess Thyroid Awareness Initiative

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Thyroid Screening Registration Form

Personal Information

Name *

Email Address

Phone *

Gender *MaleFemaleOthers

Home Address *

City

State *

Country *

Emergency/Next of Kin

Name *

Relationship *

Phone *

Medical Information

Have you been diagnosed with a thyroid condition? *YesNo

If yes, select all the symtoms that apply to you *FatigueWeight LossNeck SwellingHair LossIrregular heartbeatHeat/ Cold Sensitivity

Any family history of thyroid disease? *YesNoNot sure

Consent *

I consent to participate in this free thyroid screening. I understand that this is a screening and not a full diagnosis.

The Princess Thyroid Awareness Initiative is dedicated to improving public awareness of thyroid disorders and encouraging early diagnosis through education and community outreach.

Contact Information

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+2348032194900, +447383252884
info@ptaifoundation.org

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