Child Patient Registration
Please upload a profile photo.
Child Name:
Please enter a valid child name (letters and spaces only).
Date of Birth:
Please select a valid date of birth (age 1–20 years).
Age:
Age must be between 1 and 20.
Class:
Please enter class (alphanumeric only).
Father Name:
Please enter a valid father's name.
Aadhar Number:
Please enter a 12-digit Aadhar number.
School Name:
Please enter a valid school name.
Full Address:
Please enter the address.
District:
Select District
Agar Malwa
Alirajpur
Anuppur
Ashoknagar
Balaghat
Barwani
Betul
Bhind
Bhopal
Burhanpur
Chhatarpur
Chhindwara
Damoh
Datia
Dewas
Dhar
Dindori
Guna
Gwalior
Harda
Hoshangabad
Indore
Jabalpur
Jhabua
Katni
Khandwa
Khargone
Mandla
Mandsaur
Morena
Narsinghpur
Neemuch
Niwari
Panna
Raisen
Rajgarh
Ratlam
Rewa
Sagar
Satna
Sehore
Seoni
Shahdol
Shajapur
Sheopur
Shivpuri
Sidhi
Singrauli
Tikamgarh
Ujjain
Umaria
Vidisha
Please select a district.
Home Contact Number:
Enter a valid 10-digit mobile number.
Family Medical History
Sickle Cell (If yes, name):
BP or Sugar (If yes, name):
Poor Eyesight (If yes, name):
Paralyzed (If yes, name):
Heart Attack (If yes, name):
Health Measurements
Weight (kg):
Please enter weight.
BMI (%):
Blood Group:
Select Blood Group
A+
A-
B+
B-
AB+
AB-
O+
O-
Please select a blood group.
Height (cm):
Eye:
Teeth:
Register Child