APPLICATION FORM - RxDx
Mandatory list of documents to be Submitted
• In order to be considered for an internship, you must complete and submit this application form

• Please enclose an essay, in less than 1000 words, stating the benefits of pursuing internship at Telerad RxDx clinic
or in the healthcare sector, the area/s in which you are interested, and your personal and professional goals. ( Email )

• Provide documentation of past immunization history ( Email)

• 2 passport size photographs (submit hard copies)

• Address proof ( Email)

• ID proof ( Email)

Email to sai.aditya@rxdx.in

Name *
Complete Name
Your answer
Date Of birth *
MM
/
DD
/
YYYY
Gender *
Blood Group *
Your answer
Parent / Guardian Name *
Your answer
Residential Address *
Your answer
Email address *
valid email ID
Your answer
Contact number *
Your answer
Emergency contact Number *
Your answer
School Name & Address *
Your answer
Grade *
Session applying for in 2018 *
Note: Each session will get completed in the duration of three Weeks (Monday – Friday).
Specific Interests ( If any)
Interested in the field of radiology or Interested in occupational therapy / psychology / Cardiology
Your answer
Please tick the applicable, if “YES” please provide necessary document *
Yes
No
FOOD ALLERGIES
ALLERGIES TO MEDICINES
PAST MEDICAL HISTORY
ANY SURGERIES
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