IOACON REGISTRATION FORMAT DOCTOR DETAILS

Title
Sr. No Division Region HQ PSO Name (Dr)

EXAMPLE GENCARE MUMBAI MUMBAI 1 RAVINDRA LODH Dr.

1 Dr.
2 Dr.
3
4
5
6
7
8
9
10
REGION TOTAL REGISTRATION COST
Note: Following are fee amounts for ioacon fees registration. Enter applicable fees in given column
1. Registration Doctor : Member Rs.12500/- , Non member Rs.18500/-
2.Registration Accompanying Person (above 8 years age) : Rs. 8500/-
3. Registration PG Student Rs.9500/-
4.CME Fees: Member Rs.3700/-, Non Member Rs.4200/-, PG Student Rs.2200/-, Accompanying Person
5. Banquet : Rs.4000/- per person
 DOCTOR DETAILS

First Name Middle Name Last Name Email ID Mobile No

RUSHIKESH MADHUKAR PATIL r.patil@gmail.com 9820688159

fees in given column

/-, Accompanying Person Rs.2500/-

 Gender Medical Council State of Medical
Phone No (Male / Female) Date of Birth Registration No. Council

022-68645988 MALE 5/14/1978 MUM2350 MAHARASHTRA

 Address City Name State Name Country Name

A3- GOLDEN
MUMBAI MAHARASHTRA INDIA
CHAMBER, ANTOP HILL
 COVID 19 COVID 19 Vaccine Ref
Pin Code Dose 1 Date Dose 2 Date No.

400024 01/04/2021 5/5/2021 6843

 Registration Category Name IOA
Registration
(Member / Non-Member / PG Student / Senior Membership Fee Amount
Citizen (IOA Member Above 65 Years) Number

MEMBER LM0001 12500

 ACOOMPANYING PERSON- 1 DET

CME CME Banquet Banquet Title

(YES / NO) Fee Amount (YES / NO) Fee Amount (Mrs/Ms/Mr)

YES 3700 YES 4000 Mrs

MPANYING PERSON- 1 DETAILS

Accompanying Accompanying Relationship Registration

First Name Last Name with Doctor (YES / NO)

SONALI PATIL WIFE YES

 Regsitration CME CME Banquet Banquet
Amount (YES / NO) FEE AMOUNT (YES / NO) Fee Amount

8500 NO 0 YES 4000

 ACOOMPANYING PERSON - 2 DETAILS

COVID 19 COVID 19 Vaccine Title Accompanying

Dose 1 Date Dose 2 Date Ref No. (Mrs/Ms/Mr) First Name

4/5/2021 5/6/2021 5478

- 2 DETAILS

Accompanying Relationship Registration Regsitration

Last Name with Doctor (YES / NO) Amount
 CME CME Banquet Banquet COVID 19
(YES / NO) FEE AMOUNT (YES / NO) Fee Amount Dose 1 Date
 TOTAL COST

COVID 19 Vaccine
Dose 2 Date Ref No. Net Amount

32700

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