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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 *