SFRD Healthcare Professional Network - Onboarding & Partnership Form

Section A: Personal & Professional Identity

Welcome to the SFRD National Healthcare Professional Network. Thank you for considering this partnership. This section helps us verify your professional credentials and create your profile in our secure, internal directory.

Full Name (with Title) *

Date of Birth *

Gender *

Primary Professional Email *

This will be your primary communication ID.

Mobile Number *

For communication from the SFRD Secretariat team. This will not be shared with patients.

Medical Council Registration Number *

Registering Council *

LinkedIn Profile URL (Optional)

Sharing this helps us understand your professional background better.

Unique Expert Identifier

Your permanent identification no in SFRD. Helps you login into SFRD Framework.

Upload Credentials

Upload a copy of your medical license, degree, or other relevant credentials. (PDF, JPG, PNG)

Section B: Specialization & Employment

This information is crucial for us to understand your expertise and to ensure we refer the most relevant cases to you.

Primary Specialization *

Sub-specialization(s) *

Highest Professional Qualification(s) *

MBBS MD MS DM MCh DNB PhD MSc (Genetic Counselling)

Total Years in Practice *

Current Employment Status

Name of Primary Institution/Hospital

Address, City & State of Practice *

Section C: Rare Disease Experience & Expertise

Do you have hands-on experience in treating rare diseases? *

Yes No

Section D: Your Engagement with SFRD

This section defines how you would like to engage with patients referred by SFRD. Your contribution, in any capacity, is invaluable.

I am willing to accept SFRD referrals for: *

Virtual Case Review Virtual Consultation In-Person Consultation Diagnosis Assistance

Name of Institution/Hospital & Address where you would consult In-Person *

Consultation Fee for SFRD-referred patients:

Available hours per week for SFRD activities: *

Emergency Contact Details *

This number will be kept confidential and used by the SFRD Secretariat only for urgent, time-sensitive case discussions.

Section E: Contributing to the Mission

Beyond clinical care, your expertise can strengthen our entire ecosystem. Please let us know how else you might be interested in contributing.

I am interested in contributing towards SFRD's mission in the following ways:

Patient Identification & Diagnosis (e.g., Identify /referrals, screening new patients as part of panel of specialist doctors for a group disease, diagnostics) Education & Empowerment (e.g., Speaker for CMEs, Webinars, Translation & vetting of medical grade text information, vetting of content / creatives for social, print & electronic mediums, Research in RDs) Patient Support (e.g., 'Ask the Expert' sessions for families, Counselling) Advocacy (e.g., Reviewing policy documents for medical accuracy) Mentorship & Teaching (Guiding junior doctors in the SFRD network)

Section F: Professional Consent & Agreement (Whole Section was mandatory)

Please read the following statements carefully. This agreement formalizes your voluntary partnership with the Saba Foundation for Rare Diseases and clarifies how your professional information will be used.

I understand that my partnership with SFRD is voluntary and I can choose to end my association at any time by providing written notice. I consent to SFRD securely storing my professional information provided in this form in its internal, verified database of healthcare professionals. I consent to SFRD sharing my Name, Specialization, and City of Practice with patients/caregivers who are seeking a specialist, only after they have been screened by the SFRD support team. I understand my direct contact details (phone/email) will not be shared without my explicit permission on a case-by-case basis. I agree to uphold the highest standards of medical ethics and maintain strict patient confidentiality for all cases and information shared with me through the SFRD network, in accordance with the guidelines of the National Medical Commission. I agree to share Photographs or videos taken of me on a site may be used by SFRD for promotional purposes. Monetary Waiver: I hereby waive all claims to monetary benefits for services rendered as a Volunteer on a 'Without Compensation Basis' for an indefinite period. This agreement may be cancelled by either party upon written notice. I understand that failure to comply with any of these conditions may result in my exit from SFRD Network. By checking this box, I confirm that all the information provided is accurate to the best of my knowledge and I agree to the terms of this partnership.

Full Name (as a digital signature) *

Date

Digital Signature *