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Certificate Course in Palliative Care (CCPC)- Batch- III
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Father’s Name
Gender
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Date of Birth
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Current Affiliation
Private Practice
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Medical college/teaching affiliation
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State
Center
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Type of Registration *
MCI
State Medical Council
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Communication Address*
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Preferred mailing address
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Email Address
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Mobile Number
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Highest Qualification (Attach Proof)
*
Qualification
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Dept
Year
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Total professional/clinical experience (in years)
Palliative Care Experience (in Years)
Average number of patients treated per month
Average monthly Palliative Care patients treated
Experience Details
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Organization
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To
Location of Practice
*
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Have you attended any other PHFI course?
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I hereby declare that the above mentioned information, which I have provided, is true to the best of my knowledge. I also give my consent for publishing my feedback/testimonial which I forward to the Secretariat in any report or publication produced by PHFI & Pallium India. I understand that Course is not a degree but only a certificate course with the objective of training doctors in prevention and management of Palliative Care and successful participants are not entitled to mention/call themselves as Palliative Care Specialist anywhere after completion of this course. I also understand that this certificate course is not recognised Medical Qualification, under section 11 (1) of the Indian Medical Council Act 1956 and the Institution offering this course is neither a medical college or a university nor offering the course in accordance with the provisions of the Indian Medical Act of the University Grants Commission Act.