<%@ Page Language="C#" AutoEventWireup="true" CodeFile="Register_Doctor.aspx.cs" Inherits="Register_Doctor" EnableEventValidation="true" %> <%@ Register Assembly="AjaxControlToolkit" Namespace="AjaxControlToolkit" TagPrefix="cc1"%> CITIZEN FORCE FOUNDATION FOR CITIZENS

Registrations will be commenced soon........

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Doctor Registration

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Doctor Registration
Your Name, Qualification, Specialization, Contact Details and Availability Times etc., will be displayed in "Services->Doctors->Doctors In My Area" by default.
In case, you do not wish to display the same BUT requires only personal protection under Citizen Category, please UNCHECK the box here.
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YOU CAN EDIT FROM TIME TO TIME THE INFORMATION PROVIDED HERE IN CERTAIN FIELDS AT ANY TIME THROUGH "LOGIN"
Pincode*
 :
State
 :
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District
 :
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Mandal / Taluk*
:
Post Office Name*
 :
City / Town / Village :
Land Mark To Reach You Easily :
Locality / Area :
Street Name :
Ward / Division Number :
House Number :
Appartment Name & Number :
Availability :
Days Timings(Eg: 24 Hours, 9AM-12NOON, 4PM-9PM ETC...)
Specific dates on which not available :      You can edit from Time to Time
Salutation* :
Gender :
Doctor's Name* :
Qualification :
Specialization : <%----%> ALLERGY AND IMMUNOLOGY ANAESTHETICS CARDIOLOGY CARDIOTHORACIC SURGERY CHILD AND ADOLESCENT PSYCHIATRY AND PSYCHOTHERAPY CLINICAL NEUROPHYSIOLOGY DERMATO-VENEREOLOGY EMERGENCY MEDICINE ENDOCRINOLOGY FORENSIC MEDICINE GASTROENTEROLOGY GENERAL SURGERY GERIATRICS GYNAECOLOGY AND OBSTETRICS INFECTIOUS DISEASES INTERNAL MEDICINE INTERVENTIONAL RADIOLOGY MICROBIOLOGY NEONATOLOGY NEPHROLOGY NEUROLOGY NEURO-RADIOLOGY NEURO-SURGERY NUCLEAR MEDICINE OCCUPATIONAL MEDICINE OPHTHALMOLOGY ORAL AND MAXILLOFACIAL SURGERY ORTHOPAEDICS OTHERS - SPECIFY OTORHINOLARYNGOLOGY PAEDIATRIC ALLERGOLOGY PAEDIATRIC CARDIOLOGY PAEDIATRIC ENDOCRINOLOGY AND DIABETES PAEDIATRIC GASTROENTEROLOGY, HEPATOLOGY AND NUTRITION PAEDIATRIC HAEMATOLOGY AND ONCOLOGY PAEDIATRIC INFECTIOUS DISEASES PAEDIATRIC NEPHROLOGY PAEDIATRIC RESPIRATORY MEDICINE PAEDIATRIC RHEUMATOLOGY PAEDIATRIC SURGERY PAEDIATRICS PATHOLOGY PHARMOCOLOGY PHYSICAL AND REHABILITATION MEDICINE PLASTIC, RECONSTRUCTIVE AND AESTHETIC SURGERY PNEUMOLOGY PSYCHIATRY PUBLIC HEALTH RADIOLOGY RADIOTHERAPY RHEUMATOLOGY TROPICAL MEDICINE UROLOGY VASCULAR MEDICINE VASCULAR SURGERY
Address :
Land Mark :
Doctor's Emergency Contact Number
[In case patient want to contact you]		 : Land line:  -   Mobile: +91-
Email address :
Confirm Email address : <%----%>
Your Personal Mobile number (This will be your Login ID and to receive/retrieve forgot password)* : +91-(Password will be sent to this mobile)
Conform Mobile number* : +91-
Do you wish to a Primary Volunteer? :
Yes No
Do you wish to disclose Your Identity as a Primary Volunteer? :
Yes No
BLOOD GROUP*
 :

Emergency Contact Details: [In case you are in emergency, to whom we shall inform?]
 : <%----%>
Contact Person : RelationShip : Phone No :
Contact Person : RelationShip To : Phone No :
Your Physical Status
 :
Upload Photo :
Are you interested in BLOOD DONATION in case of emergency to anyone? [ Please consider to say YES: Humanity is Godliness]
 :
Privacy statement:
 :

Date & Time
 :
Security Code :
Enter Security Code* :
Form Filled By* :
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