Deprs " Doctors Electronic Patient Record System "

PATIENT REGISTRATION FORM

PERSONAL INFORMATION

User Name:	*		Gender:	*

Password:	*		DOB: (mm/dd/year)

Confirm Password:	*		NIC / NID:	*

First Name:	*		Marital Status:	*

Middle Name:			Profession:

Last Name:	*

Father's Name:	*

Mother's Name:

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Note: Fields marked with * are required.

DOCTOR REGISTRATION FORM


PERSONAL INFORMATION

User Name:		*	Gender:	*

Password:		*	DOB:	*

Confirm Password:		*	NIC / NID:

First Name:		*	Avg Encounter Time:	*

Middle Name:			Encounter Fee: (Rs)	*

Last Name:		*

Reg No:		*

Speciality:		*

Details:

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Note: Fields marked with * are required.