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Patient Registration
Sadman Chowdhury / Pexels
Patient Registration
(*) Required Fields
Patient Name (*)
Mobile Number
Email
Password
[ Minimum 6 Max 20 characters ]
Confirm Password
Father's Name (*)
Mother's Name (*)
[ Either Father's Name or Mother's Name is Required ]
PIN (*)
--- Select ---
263635
263641
263639
263642
422213
422214
422204
State (*)
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District (*)
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Block (*)
--- Select ---
Cluster Name (*)
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Village Name (*)
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Gender (*)
--- Select ---
Male
Female
Others
Age
ID Proof
--- Select ---
Aadhaar Card
Driving Licence
PAN Card
Voter Card
Others
Voter Card No. (*)
Aadhaar Card No. (*)
PAN Card No. (*)
Driving Licence No. (*)
Others (*)
ID Image Upload
Take Picture
Start User Media
Snap Photo
Please Check Photo in
Downloads Folder
Patient Photo Upload
Consent Form Upload
2+6 = ?
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