Doctor Enrollment Form
First Name
*
Middle Name
Last Name
Sex
*
Male
Female
Transgender
Qualification
*
Area of Specialization
Designation
Registration Number (MCI/TCMC)
*
Registration Type
*
MCI
TCMC
Registration Year
*
Email
*
Mobile Number
*
Mark as WhatsApp No
Alternate Mobile Number
Mark as WhatsApp No
WhatsApp Number
Landline Number (Off)
Landline No.(Res.)
Address
City/Town
*
State
--Select--
District
--Select--
Postal Code
Currently Working As
Currently Working Place
Preferred Mode Of Communication
*
Preference
Mode of Communication
First
SMS
WhatsApp
Email
Second
SMS
WhatsApp
Email
Third
SMS
WhatsApp
Email
Preferred Device for Teleconsultation
*
Preference
Device
First
Desktop/Laptop
Tablet
Mobile
Second
Desktop/Laptop
Tablet
Mobile
Third
Desktop/Laptop
Tablet
Mobile
Type of Phone/Tablet
Android
iOS
Windows
Other
Network Connectivity
*
4G
3G
WiFi
IP
Wired (Broadband/Leasedline)
IP
Availability for Consultation
*
Day
Preference
Monday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Tuesday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Wednesday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Thursday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Friday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Saturday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Sunday
Forenoon (FN)
Afternoon (AN)
Full-day
Not Available
Hospital
*
If Hospital/Clinic is not listed, enter your hospital/clinic/other org details
*
Hospital/Clinic
*
Type
*
--Select--
Specialty Hospital
Nodal Hospital
Mobile Telemedicine Bus
Hospital\Clinic\Other Org to map Bus/Van
*
--Select--
Organization Category
Hospital
Clinic
Other
Address
*
City/Town
*
State
*
--Select--
District
*
--Select--
Postal Code
*
Email
*
Landline Number
*
Alternate Landline Number
WhatsApp Number
Contact Person
IP Address
Website
Roles
*
Default Role
*
--Select--
Department
*
Other
*
Login Details
Login ID
*
Password
*
Repeat Password
*
Register
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