Doctor Self Registration | Hari Om Mother Father Home Healthcare

Personal Information

Title *

First Name *

Last Name *

Gender *

Date of Birth *

Marital Status *

Blood Group with RH Factor

Differently abled *

Father Name *

Religion

Contact Information

Mobile Number *

Alternative Mobile Number

Emergency Contact Number

Email ID

Clinic / Practice Address - Line 1 *

Address - Line 2

City

State

PIN Code

Education & Registration

Primary Medical Degree *

You can add multiple degrees / fellowships.

Qualification

Name of College / University

Course Type

Passout Year

Percentage / Grade

Specialization (e.g. General Physician, Cardiologist)

Medical Council Registration Number *

Registered with (Council / State) *

Registration valid till (Year)

Preferred Modes of Consultation

Home visit Teleconsultation

Languages you can consult in

Total Years of Experience

Upload Degree Marksheets (multiple files)

Upload Degree / Registration Certificates (multiple files)

Aadhar Card Upload (multiple files)

Passport Size Photo Upload

Experience

You can add multiple hospitals / clinics.

Hospital / Clinic Name

Designation

Joining Date

Still working here

Last Working Date

Current / Last CTC

Bank Details

Bank Name *

Name on Passbook *

Account Number *

Re-enter Account Number *

IFSC Code *

Mobile Number (linked with bank)

I confirm that the information provided above is true and correct to the best of my knowledge. I understand that providing false information may lead to rejection of my registration or termination of engagement.