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Full Name

Gender

Date of Birth

Profile Picture (Optional)

Email Address

Phone Number

Please enter a valid 10-digit phone number.

Password

Confirm Password

Medical Registration Number

Specialization

Years of Experience

Qualifications

Medical School/College

Clinic/Hospital Name

City

State/Region

Postal Code

Clinic Contact Number

Clinic / Hospital Address

Medical License/Registration Proof

Specialization Certificate (Optional)

ID Proof (ADHARD OR VOTER ID)

Bank Name

Account Number

IFSC Code

Account Holder Name

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