Telemedicine E clinic Reg Form

Name Of Doctor Assistan (H.W.)

Father Name

Date of Birth

Gender

Category

Educational Qualification

Qualification

Board/University/Council

Roll No./Enrollment No.

Percentage/Grade

High School

Intermediate

Paramedical/Allied Health

Permanent Address-

Village/Mohalla

Post/House No.

Distt.

Pin

State

ID Details

Rural Telemedicine Health & Wellness Center Address-

Village/Mohalla

Post/House No.

Distt.

Pin

State

Mobile No.

Whatsapp No.

Center Building

Internet or Electric Facility Available at Your Center

If You have Experience with R.M.P.

How far is the Goverment hospital from your 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

Experience

supervisor name/code