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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.
Patient Full Name : *
Father's Name : *
Mother's Name : *
Patient Address : *
Patient Email : *
Patient Mobile : *
(Don't use +88 or any space in the number, Use 11 digit mobile no like 01xxxxxxxxx)
Login Name : *
Login Password : *
Retype Password : *
Gender : *
Date of Birth : *
Security Code :  *
  * By clicking Sign Up, you agree to our Terms & Conditions.

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