RI Expert Membership Form

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Please fill the form to register with Retina India Expert Panel. Your information may be provided on the website for the sake of helping patients find you as an expert.

First name *

Last name *

Hospital *

Address1

Address2

City *

State *

Country

Please mention the name of the country if you are from a country other than INDIA.

Landline *

Phone number for a patient to call.

Mobile

This will be for our records & will not be shared in public.

Email *

This will help us contact you & will not be shared in public.

Date of Birth

DD/MM/YY - The year is not compulsory.

Sex *

Male

Female

Educational Qualifications *

Please mention your highest degree

Field of expertise *

Please choose one.

Retina

Uveitis

Cataract

Cornea

Glaucoma

Oculoplastics

Pediatric Ophthalmology

Neuro-ophthalmology

Optometrist

Other

If you have chosen 'other' in the question above, please mention your expertise.

Would you like to be added to the Doctors of Retina India e-group? *

Please choose one.

Yes

Would you like to speak at the Retina India Chapter meetings? *

Please choose one.

Yes

Would you like to write medical articles for the website/newsletter? *

Please choose one.

Yes

Would you like to help raise funds for the organization? *

Please choose one.

Yes

Would you like to donate money to Retina India? *

Please choose one. (Your donation will be tax exempt as per 80G. We will send you a receipt for it.)

Yes

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