IHMA

1/4741, Eranjipalam P.O., Kozhikode - 673 006, Kerala (+91) 978 945 5653 ihmaofficial@gmail.com

Existing IHMA Member Registration Form

MEDICAL DESIGNATION

Full Name

MEDICAL QUALIFICATION

MEDICAL REGISTRATION NUMBER

MEDICAL REGISTRATION UNIVERSITY

MEDICAL REGISTRATION STATE

MEDICAL REGISTRATION COUNCIL

IHMA Membership Category

IHMA Chapter Name

IHMA Chapter State

IHMA Chapter City

IHMA MEMBERSHIP REGISTRATION NUMBER

IHMA MEMBERSHIP EXPIRY DATE.

Full Address

Pincode

Town/Taluka

(Whatsap Enabled)

Valid Adhar NO.

Valid E-Mail ID

Website Link/Url

Year Of Practice

I would like to receive updates from IHMA National via Email/WhatsApp

I CONSENT TO SHARE MY DETAILS WITH IHMA TECH TEAM.

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1/4741, Eranjipalam P.O., Kozhikode - 673 006, Kerala

ihmaofficial@gmail.com

(+91) 978 945 5653

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