New Patient Registration

We strongly discourage to create more than one user account for an individual in order to monitor and evaluate individual special child properly through ERP based system. In case of creating more than one account, all IDs will be temporarily blocked and deposited money will NOT be refunded.

Child Information

Patient Full Name :	*
Login Name :	*
Login Password :	*
Retype Password :	*
Gender :	*
Blood Group :	*
Date of Birth :	*
Patient Address :	*
Patient Email :	*
Patient Mobile :	* (Don't use +88 or any space in the number, Use 11 digit mobile no like 01xxxxxxxxx)
Family Type :

Cousin Marriage	:
Genetic Disorder (If Yes then Write Detail)	:
Number of Family Members	:
Disabilities in Family Member	:
Child Position of Siblings	:
Number of Siblings and Age	:
Disabilities in Siblings	:
Child mostly spends time with	:
Child School (If any)	:
Preferred Family Language	:
Exposer Time	:	Hour per day

Parents & Family Information

Father's Name	:	*	Mother's Name	:	*
Father's Age	:	Y	Mother's Age	:	Y
Father's Blood Group	:		Mother's Blood Group	:
Father's Health	:		Mother's Health	:
Father's Salray	:		Mother's Salary	:
Father's Education	:		Mother's Education	:
Father's Employment	:		Mother's Employment	:

Security Code :		*
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	Already Have Accounts

New Patient Registration

Child Information

Parents & Family Information

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