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*Salutation :----Select----Dr.Dr (Mrs).Dr (Ms).Prof.

Full Name :(*As appear in NIC or Travel document)

*Name With Initials :

Preferred Name :

*NIC No:(National Identity Card No Number)

Gender :

Male

Female

*Date of Birth :

Contact Information

*Email

*Confirm Email

Postal Address :

Place of Work (or last place of work)

Province-----Select------CentralEasternNorth-CentralNorth-WesternSabaragamuwaSouthernWesternUva

*Hospital / Institute :

*Post :----Select----Consultant RadiologistActing RadiologistSenior Registrar

Contact Phone Numbers :

Mobile

Office

Residence

Fax

*Preferred contact number for Communication :

Professional Qualification

Medical Degree (with details) :

Medical School :

Post Graduate Qualifications (with dates) :a). Diagnostic Radiology/ Radiotherapy & Oncology. b). Other Qualifications

Date of Board Certification :

Special Interest

Special Interest :

User Credentials

*Username

*Password

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