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Certificate Course in Healthcare Technology (CCHT)
Participant Enrolment Form
*Mandatory to be filled.
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Gender
*
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Date of Birth
*
Current Affiliation
*
Private Practice
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Medical college/teaching affiliation
*
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No
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State
Center
Private
Location of Practice
*
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Communication Address*
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Preferred mailing address
Place of Work
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Email Address
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Mobile Number
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WhatsApp Number
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Highest Qualification (Attach Proof)
*
Qualification
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Year
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Type of Registration *
MCI
State Medical Council
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Total professional/clinical experience (in years)
*
On a scale of 5, how much are you involved with Health Technology in your job
*
1
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3
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5
On a scale of 5, let us know your proficiency in technology
*
1
2
3
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5
Any special IT qualifications that you have?
*
I hereby declare that the above-mentioned information, which I have provided, is true to the best of my knowledge. I shall participate in the online Certificate Course in Healthcare Technology and will devote self- reading time for the entire five modules and participate in the assessments, organized by the offering institution. I also give my consent for publishing my feedback/testimonial which I forward to the secretariat in any report or publication produced by PHFI. I understand that this course is not a degree but only an online course with the objective of training the healthcare professionals in healthcare technology related issues in the field of healthcare and is intended for general education and information purpose only. Participant are not entitled to mention/call themselves as Healthcare Technology specialist anywhere after completion of this course. I also understand that this certificate course is not recognized 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.