New Registration for Medical Service Booking

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.

Login details

4 to 30 characters, no spaces.

Password*

Retype password*

Child information

Patient full name*

Gender*

Blood group*

Date of birth*

Family type

Contact

Mobile*

Don't use +88 or any space in the number. Use the 11 digit mobile no like 01xxxxxxxxx.

Email*

Address*

Parents

Father's name*

Mother's name*

More about parents (optional)

Father's age (years)

Mother's age (years)

Father's blood group

Mother's blood group

Father's health

Mother's health

Father's salary

Mother's salary

Father's education

Mother's education

Father's employment

Mother's employment

Family background

Optional

Add family background

Cousin marriage

Genetic disorder

If yes, disorder detail

Number of family members

Disabilities in family members

Child position among siblings

Number of siblings and age

Disabilities in siblings

Child mostly spends time with

Child school (if any)

Preferred family language

Exposure time (hours per day)

Security code*

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New Patient Registration

Login details

Child information

Contact

Parents

Family background