Name :

Surname :

Age :

Sex :
Male Female

Residential Address :

Clinic / Hospital address :

Academic Position :

Practice Type :
Clinic Hospital Institution

Qualification :

Mobile Number :

Email Id :

Medical Council Registration :

Degree Certificate :

Photograph :

Registration fees details :
Membership fees:
Annual membership: Rs 2000 (plus GST 18%) is Rs 2360
Associate membership: (Spouse, PFT technician, Dietician, Clinical associate): Rs 1500 (plus GST 18%) is Rs 1770.