Dentist Registration Form

Basic Information

Full Name *

Email Address *

Mobile Number *

WhatsApp Number

Password / Create Login Credentials *

Profile Photo

Professional Details

Medical Registration Number / License Number *

Issuing Medical Council / Authority

Qualification (e.g., MBBS, MD, MS, etc.)

Specialization (e.g., Orthopedic, Cardiologist, etc.)

Years of Experience

Current Hospital / Clinic Name

Current Position / Designation

Languages Spoken

Consultation Type

Online

In-person

Both

Practice Details

Clinic / Hospital Address

Country

State *

District *

Area

Street Number & Building Number

Consultation Fees (Online)

Consultation Fees (Offline)

Available Days & Timings

Set your weekly hours (Google My Business style). Mark days as Closed or set start/end times. Use "Add hours" for split timings.

Day	Closed	Hours
Monday	Closed	–
Tuesday	Closed	–
Wednesday	Closed	–
Thursday	Closed	–
Friday	Closed	–
Saturday	Closed	–
Sunday	Closed	–

Emergency Consultation Availability

Yes

No

Additional Credentials

Upload Medical Degree Certificates

Upload Medical License / Registration Proof

Upload Government ID (for verification)

Upload Professional Resume / CV

Awards & Recognitions (if any)

Memberships (e.g., IMA, AAPI, etc.)

Digital Presence (Optional)

LinkedIn Profile

Website / Portfolio URL

Social Media Links

Upload Pictures (Before and After)

Upload Images and Videos

Google Map Location (Optional)

Google Map link / Share URL

Terms & Verification

I confirm that all the information provided is accurate and true.

I agree to the Terms & Conditions and Privacy Policy.

🦷 Dentist Registration