Mobile No :

Whether in Service (Government/Private/Public/Charity/Others)

If Yes, please give details:

Name of the institution:

Position held:

Service Tenure:

If held any more previous posts, kindly provide details.

Whether attached to any hospital (s) as a Specialist Consultant

If Yes, please give details

Institution (s) to which attached :

Telephone Numbers :

Hours of Availability :

Whether practicing privately

If Yes, please give details :

Whether a GP or a Specialist

Declaration

                         I hereby declare that I have been and shall be maintaining the professional ethics in my medical practice / service.  I shall limit the investigations I suggest and the prescriptions I issue only to the necessity of the condition of the patient and shall accept nothing beyond my legitimate fees / service charges and I shall not be a party for any exploitation of the innocence of the patient in any way.  By evincing such an attitude towards my profession, I shall have the satisfaction of having done my best towards the modern medical facilities are at the reach of the common man. 

                         I whole-heartedly welcome the concept of NOBLE DOCTOR and I would deem it my legitimate pride and privilege to be part and parcel thereof.

     Agree / Disagree

Station:                                Date: