Welcome to the Lhak-Sam

Membership Registration Form - Only for HIV positive


First Name:
Last Name:
Age (in yrs):
Gender:
Civil status:
Contact no:
Email:
Permanent Addres:  

Village:

Gewog:
Dzongkhag:
Education level:

Occupation:
Supported by family members?

Supported at workplace?

Year of diagnosis:
Counselling received?

Probable place of infection:
Mode of transmission:
Are you on any medication?
To what extent are you willing to come forward?

Your comments and Suggestions:
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