COVIDline.in Doctor Registration Form

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This form is for those doctors who want to do their bit to help India fight the COVID-19 crisis. If you are a registered medical practitioner then please fill this form, we will shortly get in touch with you.

Name *

Email *

The country you are living in *

e.g., Australia, USA, France, India, etc.

Please mention your highest medical degree *

e.g., MBBS, MD, DM (Gastro), M.Ch., etc.

WhatsApp number (with your country code) *

e.g., +49 987654321.....

Name of the medical institution you are associated with. *

Please mention the name of the institution and your profile link (if available), or mention Private if you are an independent medical practitioner.

Commitment (in hours) *

1 hour on the day you want to serve

2 hour on the day you want to serve

3 hour on the day you want to serve

4 hour on the day you want to serve

6 hour on the day you want to serve

8 hour on the day you want to serve

其他:

Days in a week you want to serve *

Please select the days in a weak you are willing to serve.

Monday

Tuesday

Wednesday

Thursday

Friday

Saturday

Sunday

必填

Time Slot (Preferably in IST) *

Please mention the time slot you are willing to serve.

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