Clinic Management Form

High School


Intermediate


Paramedical/Allied Health Courses


Basic Computer & Information Technology

Rural Telemedicine Health & Wellness E-Clinic Sub-Center Address-

Village/Mohalla
Post/House No.


Distt.
Pin


State
Email Id


Mobile No.
Whatsapp No.


Center Building
Internet or Electric Facility Available at Your Center


If You have Experience with Registered Medical Practitioner(IMC Act,1956)
How Many Year Experience


Distance From the Government to Your E-Center (In kilometer).
Upload Your Photograph
Upload Your Aadhar Front/back Photograph


Upload Highschool Marksheet/Certificate Self attested
Upload Intermediate Marksheet/Certificate Self attested


Upload Paramedical/Allied Course Marksheet/Certificate Self attested
Upload Signature Doctor Assistant


Inspection officer name with code/Self



☑ I declare that all the information and statement given by me as above are true and correct. If any information and statement are found to be wrong and false submitted by me at any stage, any disciplinary action can be taken by authority.

----->