Doctor Registration form

Title *

Full Name *

Email *

WhatsApp Number *

Experience *

Consultation Charges *

Discount for every member of Behter Ellaj 25% *

Gender *

Male
Female
Other

Professional Qualifications *

	Date	Awarding Body	Qualifications Attained
1

Add Row

Specialization

	Specialization *
1

Add Row

Work Places *

	Name of Hospital/ Clinic	Address	Days	Timing
1

Add Row

PMDC License Number *

PHC License Number

Address *

Areas of Expertise *

Add Profile photo *

Title

Alternative Text

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Caption

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Posted

May 30, 2024

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Lab Registration
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Laboratory Name
Type of organization
Sole Proprietorship
Partnership
Private Ltd
Society
Others
Layout
Name of CEO
Name of focal person
Official Email
Phone
Phone
Official Email
Address
Address Line 1
City
State / Province / Region
Postal Code
Country
Departments
First Choice
Second Choice
Third Choice
Rates
Layout
Name
Phone No.
Phone No.

Hospital Registration
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Hospital Name
Type of organization
Sole Proprietorship
Partnership
Private Ltd
Society
Others
Layout
Name of CEO
Name of focal person
Phone
Phone
Address
Address Line 1
City
State / Province / Region
Postal Code
Country
File Upload
I. Doctors Name with Qualifications
II. Departments
III. PHC registration
IV. Facilities available in hospitals
V. Pharmacy ✅ ❎
VI. Diagnostics labs if outsource then name
VII. Radiology department ✅ ❎ and electrical equipment's
VIII. Number of Beds , wards and pharmacies etc.….
IX. Rates ( Quotations )

Doctor Registration

Title *
Full Name *
Email *
WhatsApp Number *
Experience *
Consultation Charges *
Discount for every member of Behter Ellaj 25% *
Gender *
Male
Female
Other
Professional Qualifications *

Date Awarding Body Qualifications Attained

1

Add Row

Specialization

Specialization *

1

Add Row

Work Places *

Name of Hospital/ Clinic Address Days Timing

1

Add Row

Specialty *

General Physician

Consultant Physician

Surgeon

Psychiatrist

Dental Surgeon

Physicist

Nutritionist

Others

PMDC License Number *
PHC License Number
Address *
Areas of Expertise *

Add Profile photo *

Add Image

Title
Alternative Text
Leave empty if the image is purely decorative.
Caption
Description

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