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Registration Form

Name *
Gender *
Date of birth *
Profile Picture
Aadhar Card No*
Scan copy of Aadhar Card
Medical Registration No *
Scan copy of Registration Certificate *
Speciality *
Educational qualification
Banking Details *

Bank account Name, Account Number, Bank Name, IFSC Code ( Kindly fill in this order)

Languages known *
Mobile No *

Alternate Contact No

Alternate Contact No
Address *
e-Mail ID *
Telemedicine Consultation Days *

Telemedicine consultation time*

(this can be changed later, if required)

Session - 1
Start time
End time
Session - 2
Start time
End time
Session - 3
Start time
End time
Telemedicine consultation fee *