Medical, Health & Family Welfare Department, Government of Rajasthan

चिकित्सा, स्वास्थ्य एवं परिवार कल्याण विभाग Department of Medical, Health & Family Welfare

श्री भजनलाल शर्मा

माननीय मुख्यमंत्री

श्री गजेन्द्र सिंह

माननीय चि. एवं स्वा. मंत्री

ESTABLISHMENT Registration Form Check Form Status

Rajasthan State Mental Health Authority
Registration Form

Details of Professional

Salutation

Full Name

DOB

Select Gender

Mobile

Identification Proof

( i.e. Driving Licence,Voter Card,Passport or Aadhar Card can serve as Photo ID )

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Profile Photo

Size should be in size 3*4 cm(Scanned copy of Profile photo(jpg, jpeg, png only)

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Upload Address Proof

( Upload Proof of Address for Work or Residence in Rajasthan)

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Work Address in Rajasthan/Location's of Practice

Present Address

Address Line 1

Address Line 2

City

District

State

Pin Code

Permanent Address

Same as Present Address

Address Line 1

Address Line 2

City

District

State

Pin Code

Discipline Information

Your Discipline

System of Medicine

Registered Under/ Act Name

Professional Experience in Psychiatry (in.years)

Registration No

Upload Registration Proof (Act Under Registered i.e. RMC, etc.)

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Education Qualification Details

Educational Specialization

Degree Name

Name of College/University

Upload Degree Document