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Program
Services
Pathologies
Beyond diagnosis
Events
Patient inscription
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Enrollment in the program
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Country*
Name of the doctor who prescribed
Doctor is not in the list /
Pacient does not know doctor's name
Select a treatment
Select a country first
Tailored Affordability Support
In case your doctor has given you a 6-letter code, enter it here
Patient’s data
First name*
Last name *
Segundo apellido
Gender*
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Female
Male
Date of birth*
Province*
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Address
Document type*
Document number*
Enter your email*
Mobile number*
Telephone
How did you hear about Celebrate life?
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Medicine
Professional
Do you want to include caregiver's data?
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Caregiver information
Caregiver name*
Caregiver last name *
Caregiver kinship*
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Direct family
Indirect family
Other
Caregiver gender*
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Female
Male
Document type*
Caregiver document number*
Caregiver email
Caregiver mobile number*
Caregiver's Mobile/Cell Phone
I accept the
sworn declaration
of tailored affordability support.
I accept the
Terms and conditions
of the current program.
I accept the
Informed consent
of the current program.
