Join As Doctor – surgibid.com

SECTION A: PERSONAL & IDENTITY INFORMATION

Fields marked with an asterisk (*) are mandatory for verification.

Full Name (as per IMR/NMR):

First

Middle

Last

Father’s Name (as per IMR/NMR):

First

Middle

Last

Date of Birth (DD/MM/YYYY):

Gender

Male
Female
Other

Aadhaar Number:

(Required for NMR Linking)

PAN Card Number:

Email:

Create Password:

Phone

Current Residential Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

SECTION B: PROFESSIONAL & ACADEMIC QUALIFICATIONS

Please list qualifications in descending order (Highest degree first).

Degree (MBBS/MD/MS/DNB)

College / Institute

University

Year of Passing

Degree (MBBS/MD/MS/DNB) (copy)

College / Institute (copy)

University (copy)

Year of Passing (copy)

Degree (MBBS/MD/MS/DNB) (copy) (copy)

College / Institute (copy) (copy)

University (copy) (copy)

Year of Passing (copy) (copy)

Total Years of Experience (Post-MBBS):

Specialization / Area of Expertise

SECTION C: STATUTORY REGISTRATION DETAILS

Failure to provide valid registration will result in profile rejection.

Medical Council Registration Number:

Name of State Medical Council:

Date of Original Registration:

Valid Upto:

SECTION D: PRACTICE & CLINIC DETAILS

Primary Clinic/Hospital Name:

Languages of (copy)

Clinic Address:

Address Line 1

Address Line 2

City

State / Province / Region

Postal Code

Country

Consultation Fees (INR):

In-Person: ₹

Teleconsultation: ₹

Languages Spoken:

English
Hindi
Regional

Regional:

SECTION E: MANDATORY DOCUMENT CHECKLIST

Please attach self-attested photocopies of the following:

Self-Attested Medical Registration Certificate (SMC/NMC)
Internship Completion Certificate
Degree Certificates (MBBS & Post-Graduation)
Copy of Aadhaar Card / Passport
One (1) Recent Passport Size Photograph

SECTION F: DECLARATION

I, Dr. ____________________________________, hereby declare that I am a Registered Medical Practitioner (RMP) currently enrolled with the __________________________ Medical Council. I certify that the information provided above is true and that I will adhere to the NMC Code of Ethics and Telemedicine Practice Guidelines.

Signature of Doctor: __________________________ Date: _________________

Seal / Stamp:

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