Registration form for Volunteers - Telemedicine Consultation

Name: Father Name:

Address: Mobile No. for Consultations:  

Registration No. (Medical Council/State Council/Dental Council): Speciality

Preferred time for Consultation
From Time:
(Please enter in 24 hrs format i.e. 00:01 to 23:59)
  To Time:
(Please enter in 24 hrs format i.e. 00:01 to 23:59)
 

Disclaimer : No Payment will be made for Giving Volunatry Consultations