Long Term Fellowship 2 Faculty in Ophthalmology - LVPEI

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Patient information
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Support us
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About us
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Applicant Name(Required)

Firstname Lastname

Father's Name / Spouse Name(Required)

Firstname Lastname

Date of Birth(Required)

Applicant Email(Required)

Applicant Phone(Required)

Address(Required)

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Gender(Required)

Male

Female

Other

Marital Status(Required)

Nationality(Required)

Qualification(Required)

Institute / University(Required)

MCI(Required)

State Medical Registration(Required)

Present Place of Work/Training(Required)

Designation(Required)

First choice of preference(Required)

Glaucoma

Pediatric-ophthalmology-strabismus-and-neuro-ophthalmology

Cornea and Anterior Segment

Retina and Vitreous

Oculoplasty and Ocular Oncology

Uveitis Medical Retina

Second choice of preference(Required)

Glaucoma

Pediatric-ophthalmology-strabismus-and-neuro-ophthalmology

Cornea and Anterior Segment

Retina and Vitreous

Oculoplasty and Ocular Oncology

Uveitis Medical Retina

Year of Completion(Required)

Percentage of marks(Required)

Name of the institution, University

DO – Year of completion

Percentage of marks

Name of the institution, University

MS – Year of completion

Percentage of marks

Name of the institution, University

MD – Year of completion

Percentage of marks

Name of the institution, University

DNB – Year of completion

Percentage of marks

Name of the institution, University

DOMS – Year of completion

Percentage of marks

Name of the institution, University

ECCE No. of surgeries performed under supervision

ECCE No. of surgeries performed independently

ECCE comfort level on scale of 1-5

Trabeculectomy No. of surgeries performed under supervision

Trabeculectomy No. of surgeries performed independently

Trabeculectomy comfort level on scale of 1-5

SICS No. of surgeries performed under supervision

SICS No. of surgeries performed independently

SICS comfort level on scale of 1-5

Retina Lasers performed under supervision

Retina Lasers performed independently

Retina Lasers comfort level on scale of 1-5

PHACO No. of surgeries performed under supervision

PHACO No. of surgeries performed independently

PHACO comfort level on scale of 1-5

DCT No. of surgeries performed under supervision

DCT No. of surgeries performed independently

DCT comfort level on scale of 1-5

DCR No. of surgeries performed under supervision

DCR No. of surgeries performed independently

Other surgeries comfort level on scale of 1-5

Other surgeries performed under supervision

Other surgeries performed independently

DCR comfort level on scale of 1-5

Other Studies (Mention any other studies undertaken, including training/refresher courses not exceeding 100 words)

Fellowships and Scholarships (Which of above studies were undertaken with a fellowship or scholarship? Mention the sponsor of the grant not exceeding 100 words)

Visits abroad / Publications and Research (List any significant vists abroad not mentioned above) (List any significant publication (including publisher and date of publication) and any major research projects undertaken not exceeding 100 words

Full Name

First Last

Address

Street Address Address Line 2 City County / State / Region ZIP / Postal Code Country

Recent passport size photo

Max. file size: 18 MB.

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