REGISTRATION FORM (E-CLINIC)

(RURAL TELEMEDICINE HEALTH & WELLNESS CENTER)

    Name Of Doctor Assistant (H.W.)



    Father's Name
    Date of Birth


    Gender
    Category


    Permanent Address-

    Village/Mohalla
    Post/House No.


    Distt.
    Pin Code


    State
    ID Details


    Educational Qualification -

    High School


    Intermediate


    Paramedical/Allied Health Courses


    Basic Computer & Information Technology

    Rural Telemedicine Health & Wellness E-Clinic Center Address-

    Village/Mohalla
    Post/House No.


    Distt.
    Pin


    State
    Email Id


    Mobile No.
    Whatsapp No.


    Center Building
    Internet or Electric Facility Available at Your Center


    If You have Experience with Registered Medical Practitioner(IMC Act,1956)
    How Many Year Experience


    Distance From the Government to Your E-Center (In kilometer).
    Upload Your Photograph
    Upload Your Aadhar Front/back Photograph


    Upload Highschool Marksheet/Certificate Self attested
    Upload Intermediate Marksheet/Certificate Self attested


    Upload Paramedical/Allied Course Marksheet/Certificate Self attested
    Upload Signature Doctor Assistant


    Inspection officer name with code/Self



    ☑ I declare that all the information and statement given by me as above are true and correct. If any information and statement are found to be wrong and false submitted by me at any stage, any disciplinary action can be taken by authority.