www.bdsdentist.com
Open in
urlscan Pro
167.86.119.178
Public Scan
URL:
https://www.bdsdentist.com/home/index.htm
Submission: On September 23 via api from US — Scanned from US
Submission: On September 23 via api from US — Scanned from US
Form analysis 10 forms found in the DOM
<form id="reg_dental_camp_form">
<div class="form-group mb-3"><input type="text" id="reg_name" name="reg_name" placeholder="Name" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="email" id="reg_email" name="reg_email" placeholder="Email" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="text" id="reg_phone" name="reg_phone" placeholder="Phone Number" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><select id="reg_type" name="reg_type" class="form-control color-default rounded-pill">
<option value="">Select</option>
<option value="Doctor">Doctor</option>
<option value="Company">Company</option>
<option value="School">School</option>
<option value="College">College</option>
<option value="University">University</option>
</select></div>
<div class="form-group mb-3"><input type="text" id="reg_info" name="reg_info" placeholder="Phone Number" class="form-control color-default rounded-pill" style="display: none;"></div>
<div class="form-group text-center"><button type="button" class="btn btn-sub-modal color-default">Submit & Register</button></div>
</form><form id="apply_dental_camp_form"><input type="hidden" name="apply_userid" id="apply_userid">
<div class="form-group mb-3"><input type="text" id="apply_name" name="apply_name" placeholder="Name" readonly="readonly" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="email" id="apply_email" name="apply_email" placeholder="Email" readonly="readonly" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="text" id="apply_phone" name="apply_phone" placeholder="Phone Number" readonly="readonly" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="text" id="apply_address" name="apply_address" placeholder="Address" class="form-control color-default rounded-pill"></div>
<div class="form-group text-center"><button type="button" class="btn btn-sub-modal color-default">Submit</button></div>
</form><form id="doctor_edit_form" enctype="multipart/form-data"><input type="hidden" id="doctor_id" name="doctor_id">
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Update Image</label>
<div class="col-sm-9"><input type="file" id="file" name="file" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Image</label>
<div class="col-sm-9"><img src="https://bdsdentist.com/ubl/public/images/default.jpg" id="previewImage" class="w-25"><button type="button" id="clearButton" style="display: none;">Clear</button></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Name</label>
<div class="col-sm-9"><input type="text" id="doctor_name" name="doctor_name" placeholder="Name" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Email</label>
<div class="col-sm-9"><input type="text" id="doctor_email" name="doctor_email" placeholder="Doctor Email" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Department</label>
<div class="col-sm-9"><select id="department" name="department" class="form-control rounded-pill">
<option value="" selected="selected">Department</option>
<option value="PAEDIATRIC DENTISTRY">PAEDIATRIC DENTISTRY</option>
<option value="DEPARTMENT OF PROSTHODONTICS">DEPARTMENT OF PROSTHODONTICS</option>
<option value="ORAL ANATOMY & PHYSIOLOGY">ORAL ANATOMY & PHYSIOLOGY</option>
<option value="CONSERVATIVE DENTISTRY & ENDODONTICS">CONSERVATIVE DENTISTRY & ENDODONTICS</option>
<option value="ORAL AND MAXILLOFACIAL SURGERY">ORAL AND MAXILLOFACIAL SURGERY</option>
<option value="ORAL PATHOLOGY & PERIODONTOLOGY">ORAL PATHOLOGY & PERIODONTOLOGY</option>
<option value="ORTHODONTICS">ORTHODONTICS</option>
<option value="DEPARTMENT OF LIFE SCIENCE">DEPARTMENT OF LIFE SCIENCE</option>
<option value="PERIODENTOLOGY & ORAL PATHOLOGY">PERIODENTOLOGY & ORAL PATHOLOGY</option>
<option value="FACULTY OF DENTISTRY">FACULTY OF DENTISTRY</option>
<option value="DIAGNOSIS DEPARTMENT">DIAGNOSIS DEPARTMENT</option>
<option value="GENERAL & DENTAL PHARMACOLOGY">GENERAL & DENTAL PHARMACOLOGY</option>
<option value="DENTAL PUBLIC HEALTH">DENTAL PUBLIC HEALTH</option>
<option value="DENTAL DEPARTMENT">DENTAL DEPARTMENT</option>
<option value="HEALTH">HEALTH</option>
<option value="DENTAL ANATOMY">DENTAL ANATOMY</option>
<option value="SCIENCE OF DENTAL MATERIALS">SCIENCE OF DENTAL MATERIALS</option>
</select></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Designation</label>
<div class="col-sm-9"><input type="text" id="doctor_designation" name="doctor_designation" placeholder="Doctor Designation" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">BMDC No</label>
<div class="col-sm-9"><input type="text" id="bmdc_number" name="bmdc_number" placeholder="BMDC Number" disabled="disabled" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Specialization</label>
<div class="col-sm-9"><input type="text" id="specialization" name="specialization" placeholder="Specialization" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white" style="font-size: 15px;">Chamber Name</label>
<div class="col-sm-9"><input type="email" id="doctor_chamber_name" name="doctor_chamber_name" placeholder="Chamber Name" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white" style="font-size: 15px; padding: 0px;">Chamber Address</label>
<div class="col-sm-9"><input type="text" id="doctor_chamber_address" name="doctor_chamber_address" placeholder="Doctor Chamber Address" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white" style="font-size: 14.5px; padding: 0px;">Chamber Availability</label>
<div class="col-sm-9"><input type="email" id="doctor_chamber_availability" name="doctor_chamber_availability" placeholder="Chamber Availability" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white" style="font-size: 15px;">Education</label>
<div class="col-sm-9"><input type="email" id="doctor_education" name="doctor_education" placeholder="Doctor Education" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Phone</label>
<div class="col-sm-9"><input type="text" id="doctor_phone" name="doctor_phone" placeholder="Doctor Phone" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white"></label>
<div class="col-sm-9"><input type="checkbox" id="update_location_reg" name="update_location_reg" value="1" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> Take my current location as my chamber
location </label></div>
</div>
<div id="updateLocationDiv">
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Latitude</label>
<div class="col-sm-9"><input type="number" id="latitude" name="latitude" placeholder="Doctor Phone" class="form-control color-default rounded-pill"></div>
</div>
<div class="form-group row mb-3"><label for="staticEmail" class="col-sm-3 col-form-label color-white">Longitude</label>
<div class="col-sm-9"><input type="text" id="longitude" name="longitude" placeholder="Doctor Phone" class="form-control color-default rounded-pill"></div>
</div>
</div>
<div class="form-group text-center"><button type="button" class="btn btn-sub-modal color-default">Update</button></div>
</form><form id="user_edit_form"><input type="hidden" id="user_id" name="user_id">
<div class="form-group mb-3"><input type="text" id="user_name" name="user_name" placeholder="Name" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="text" id="user_phone" name="user_phone" placeholder="Phone" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="text" id="user_email" name="user_email" placeholder="Email" class="form-control color-default rounded-pill"></div>
<div class="form-group text-center"><button type="button" class="btn btn-sub-modal color-default">Update</button></div>
</form><form id="change_pass_form"><input type="hidden" id="pass_id" name="pass_id">
<div class="form-group mb-3"><input type="password" id="current_pass" name="current_pass" placeholder="Current Password" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="password" id="new_pass" name="new_pass" placeholder="New Password" class="form-control color-default rounded-pill"></div>
<div class="form-group mb-3"><input type="password" id="con_new_pass" name="con_new_pass" placeholder="Confirm New Password" class="form-control color-default rounded-pill"></div>
<div class="form-group text-center"><button type="button" class="btn btn-sub-modal color-default">Update</button></div>
</form><form>
<div class="row">
<div class="col-md-6 border-right2">
<div class="form-group"><input type="text" id="exampleFormControlInput12" placeholder="Name" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="exampleFormControlInput4" placeholder="Specialization" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="exampleFormControlInput6" placeholder="Chamber Name" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="exampleFormControlInput17" placeholder="Chamber Address (click to edit)" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="email" id="exampleFormControlInput18" placeholder="Email" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="number" id="exampleFormControlInput122" placeholder="Phone Number" class="form-control color-default rounded-pill"></div>
</div>
<div class="col-md-6">
<div class="text-center mb-2"><button type="button" class="btn btn-add-img">+ add image</button></div>
<div class="form-group"><input type="password" id="exampleFormControlInput62" placeholder="Create Password" class="form-control color-default rounded-pill"></div>
<div class="form-group row-position-relative"><input type="text" id="exampleFormControlInput1744" placeholder="BMDC Certificate" class="form-control color-default rounded-pill"><span class="bg-default color-white view-cert">View </span></div>
<div class="form-group"><input type="password" id="exampleFormControlInput158" placeholder="Update Password" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="password" id="exampleFormControlInput1262" placeholder="Re-enter Password" class="form-control color-default rounded-pill"></div>
</div>
</div>
<div class="row mt-3 small-inputs">
<div class="col-md-6">
<div class="text-left color-white">Select Your Working Days</div>
<div class="form-group row"><input type="text" id="exampleFormControlInput123" placeholder="Sat" class="col-md-2 color-default rounded-pill"><input type="text" id="exampleFormControlInput1266" placeholder="Mon"
class="col-md-2 color-default rounded-pill"><input type="text" id="exampleFormControlInput125" placeholder="Tue" class="col-md-2 color-default rounded-pill"><input type="text" id="exampleFormControlInput126" placeholder="Wed"
class="col-md-2 color-default rounded-pill"><input type="text" id="exampleFormControlInput127" placeholder="Thr" class="col-md-2 color-default rounded-pill"><input type="text" id="exampleFormControlInput129" placeholder="Fri"
class="col-md-2 color-default rounded-pill"></div>
</div>
<div class="col-md-6">
<div class="text-left color-white">Select Your Working Hours</div>
<div class="form-group row"><input type="text" id="exampleFormControlInput12345" placeholder="00:00" class="col-md-3 color-default rounded-pill"><input type="text" id="exampleFormControlInput124665" placeholder="AM"
class="col-md-2 color-default rounded-pill">
<div class="col-md-2 color-white text-center">To</div><input type="text" id="exampleFormControlInput125335" placeholder="00:00" class="col-md-3 color-default rounded-pill"><input type="text" id="exampleFormControlInput1212456"
placeholder="PM" class="col-md-2 color-default rounded-pill">
</div>
</div>
</div>
<div class="mt-2 text-center"><button type="button" class="btn btn-sub-modal color-default px-4 p-2">Submit & Register</button></div>
</form><form>
<div class="form-group"><label for="recipient-name" class="col-form-label">Recipient:</label><input type="text" id="recipient-name" class="form-control"></div>
<div class="form-group"><label for="message-text" class="col-form-label">Message:</label><textarea id="message-text" class="form-control"></textarea></div>
</form><form>
<div class="row">
<div class="col-md-6 border-right2">
<div class="form-group"><input type="text" id="login_email" name="login_email" placeholder="Email / BMDC No." class="form-control color-default rounded-pill"></div>
<div class="input-group mb-3"><input type="password" id="login_password" name="login_password" placeholder="Password" class="form-control color-default rounded-pill">
<div class="input-group-append"><i aria-hidden="true" class="fa fa-eye" style="position: absolute; margin-left: -25px; margin-top: 10px; cursor: pointer; z-index: 99999;"></i></div>
</div>
<div class="form-check mb-2"><input type="checkbox" id="login_agree" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> I give my consent to Unilever Bangladesh and its affiliated third parties
to use, store and process my given information and communicate with me in the future. </label></div>
<div class="form-check mb-2"><input type="checkbox" id="login_privacy" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> I agree to Unilever's
<a href="/cookies" class="" style="color: white;"> cookie </a> and <a href="/privacy" class="" style="color: white;"> privacy policy</a></label></div>
<div class="form-check mb-2"><input type="checkbox" id="login_age" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> I am at least 18 years old </label></div>
<div class="form-group"><a href="#" style="color: white;">Forgot password?</a></div>
<div class="form-group">
<div class="row">
<div class="col-6">
<div data-onsuccess="onLogin" class="g-signin2" data-gapiscan="true" data-onload="true">
<div style="height:36px;width:120px;" class="abcRioButton abcRioButtonLightBlue">
<div class="abcRioButtonContentWrapper">
<div class="abcRioButtonIcon" style="padding:8px">
<div style="width:18px;height:18px;" class="abcRioButtonSvgImageWithFallback abcRioButtonIconImage abcRioButtonIconImage18"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" width="18px" height="18px" viewBox="0 0 48 48"
class="abcRioButtonSvg">
<g>
<path fill="#EA4335" d="M24 9.5c3.54 0 6.71 1.22 9.21 3.6l6.85-6.85C35.9 2.38 30.47 0 24 0 14.62 0 6.51 5.38 2.56 13.22l7.98 6.19C12.43 13.72 17.74 9.5 24 9.5z"></path>
<path fill="#4285F4" d="M46.98 24.55c0-1.57-.15-3.09-.38-4.55H24v9.02h12.94c-.58 2.96-2.26 5.48-4.78 7.18l7.73 6c4.51-4.18 7.09-10.36 7.09-17.65z"></path>
<path fill="#FBBC05" d="M10.53 28.59c-.48-1.45-.76-2.99-.76-4.59s.27-3.14.76-4.59l-7.98-6.19C.92 16.46 0 20.12 0 24c0 3.88.92 7.54 2.56 10.78l7.97-6.19z"></path>
<path fill="#34A853" d="M24 48c6.48 0 11.93-2.13 15.89-5.81l-7.73-6c-2.15 1.45-4.92 2.3-8.16 2.3-6.26 0-11.57-4.22-13.47-9.91l-7.98 6.19C6.51 42.62 14.62 48 24 48z"></path>
<path fill="none" d="M0 0h48v48H0z"></path>
</g>
</svg></div>
</div><span style="font-size:13px;line-height:34px;" class="abcRioButtonContents"><span id="not_signed_in2t7fh0j1pk0u">Sign in</span><span id="connected2t7fh0j1pk0u" style="display:none">Signed in</span></span>
</div>
</div>
</div>
</div>
<div class="col-6"><button type="button" class="btn btn-sub-modal color-default">Login</button></div>
</div>
</div>
</div>
<div class="col-md-6"></div>
</div>
</form><form>
<div class="row">
<div class="col-md-8">
<div class="form-group"><input type="text" id="forget_email" name="forget_email" placeholder="Write your email address" class="form-control color-default rounded-pill"></div>
<div class="form-group"><button type="button" class="btn btn-sub-modal color-default">Send</button></div>
</div>
</div>
</form><form id="signUpForm" enctype="multipart/form-data">
<div class="row">
<div class="col-md-6 border-right2">
<div class="form-group"><input type="text" id="signup_name" name="signup_name" placeholder="* Name" class="form-control color-default rounded-pill asterisk"></div>
<div class="form-group"><input type="text" id="email" name="email" placeholder="* Email" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="number" id="signup_phone" name="signup_phone" placeholder="* Phone Number" class="form-control color-default rounded-pill"></div>
<div class="input-group mb-3"><input type="password" id="password" name="password" placeholder="* Password" class="form-control color-default rounded-pill">
<div class="input-group-append"><i aria-hidden="true" class="fa fa-eye" style="position: absolute; margin-left: -25px; margin-top: 10px; cursor: pointer; z-index: 99999;"></i></div>
</div>
<div class="form-group"><input type="password" id="con_password" name="con_password" placeholder="* Confirm Password" class="form-control color-default rounded-pill"></div>
<div id="userdiv" class="form-group" style="margin-bottom: 0px;"><label for="exampleFormControlSelect1" style="color: white;">I am </label><select id="role_id" name="role_id" class="form-control rounded-pill">
<option value="">* Select</option>
<option value="2">Doctor</option>
<option value="3">Patient</option>
</select></div>
<div id="filediv" class="form-group" style="display: none; margin-bottom: 0px;"><input type="file" id="file_reg" name="file_reg" class="form-control color-default rounded-pill"></div>
<div class="form-check"><label for="exampleCheck1" class="form-check-label" style="color: red; font-size: 12px;"> * Marks field are mandatory </label></div>
<div class="form-check mb-2"><input type="checkbox" id="agree" name="agree" value="1" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> I give my consent to Unilever Bangladesh and its
affiliated third parties to use, store and process my given information and communicate with me in the future. </label></div>
<div class="form-check mb-2"><input type="checkbox" id="privacy" name="privacy" value="1" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> I agree to Unilever's
<a href="/cookies" class="" style="color: white;"> cookie </a> and <a href="/privacy" class="" style="color: white;"> privacy policy</a></label></div>
<div class="form-check mb-2"><input type="checkbox" id="age" name="age" value="1" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> I am at least 18 years old </label></div>
<div class="form-group">
<div class="row">
<div class="col-6">
<div data-onsuccess="onSignIn" class="g-signin2" data-gapiscan="true" data-onload="true">
<div style="height:36px;width:120px;" class="abcRioButton abcRioButtonLightBlue">
<div class="abcRioButtonContentWrapper">
<div class="abcRioButtonIcon" style="padding:8px">
<div style="width:18px;height:18px;" class="abcRioButtonSvgImageWithFallback abcRioButtonIconImage abcRioButtonIconImage18"><svg version="1.1" xmlns="http://www.w3.org/2000/svg" width="18px" height="18px" viewBox="0 0 48 48"
class="abcRioButtonSvg">
<g>
<path fill="#EA4335" d="M24 9.5c3.54 0 6.71 1.22 9.21 3.6l6.85-6.85C35.9 2.38 30.47 0 24 0 14.62 0 6.51 5.38 2.56 13.22l7.98 6.19C12.43 13.72 17.74 9.5 24 9.5z"></path>
<path fill="#4285F4" d="M46.98 24.55c0-1.57-.15-3.09-.38-4.55H24v9.02h12.94c-.58 2.96-2.26 5.48-4.78 7.18l7.73 6c4.51-4.18 7.09-10.36 7.09-17.65z"></path>
<path fill="#FBBC05" d="M10.53 28.59c-.48-1.45-.76-2.99-.76-4.59s.27-3.14.76-4.59l-7.98-6.19C.92 16.46 0 20.12 0 24c0 3.88.92 7.54 2.56 10.78l7.97-6.19z"></path>
<path fill="#34A853" d="M24 48c6.48 0 11.93-2.13 15.89-5.81l-7.73-6c-2.15 1.45-4.92 2.3-8.16 2.3-6.26 0-11.57-4.22-13.47-9.91l-7.98 6.19C6.51 42.62 14.62 48 24 48z"></path>
<path fill="none" d="M0 0h48v48H0z"></path>
</g>
</svg></div>
</div><span style="font-size:13px;line-height:34px;" class="abcRioButtonContents"><span id="not_signed_inkrer1v5qbsro">Sign in</span><span id="connectedkrer1v5qbsro" style="display:none">Signed in</span></span>
</div>
</div>
</div>
</div>
<div class="col-6"><button type="button" class="btn btn-sub-modal color-default">Sign Up</button></div>
</div>
</div>
</div>
<div id="doctor_reg_div" class="col-md-6" style="display: none;">
<div class="form-group"><input type="text" id="designation_reg" name="designation_reg" placeholder="Designation" class="form-control color-default rounded-pill"></div>
<div class="form-group"><select id="department_reg" name="department_reg" class="form-control rounded-pill">
<option value="" selected="selected">Department</option>
<option value="PAEDIATRIC DENTISTRY">PAEDIATRIC DENTISTRY</option>
<option value="DEPARTMENT OF PROSTHODONTICS">DEPARTMENT OF PROSTHODONTICS</option>
<option value="ORAL ANATOMY & PHYSIOLOGY">ORAL ANATOMY & PHYSIOLOGY</option>
<option value="CONSERVATIVE DENTISTRY & ENDODONTICS">CONSERVATIVE DENTISTRY & ENDODONTICS</option>
<option value="ORAL AND MAXILLOFACIAL SURGERY">ORAL AND MAXILLOFACIAL SURGERY</option>
<option value="ORAL PATHOLOGY & PERIODONTOLOGY">ORAL PATHOLOGY & PERIODONTOLOGY</option>
<option value="ORTHODONTICS">ORTHODONTICS</option>
<option value="DEPARTMENT OF LIFE SCIENCE">DEPARTMENT OF LIFE SCIENCE</option>
<option value="PERIODENTOLOGY & ORAL PATHOLOGY">PERIODENTOLOGY & ORAL PATHOLOGY</option>
<option value="FACULTY OF DENTISTRY">FACULTY OF DENTISTRY</option>
<option value="DIAGNOSIS DEPARTMENT">DIAGNOSIS DEPARTMENT</option>
<option value="GENERAL & DENTAL PHARMACOLOGY">GENERAL & DENTAL PHARMACOLOGY</option>
<option value="DENTAL PUBLIC HEALTH">DENTAL PUBLIC HEALTH</option>
<option value="DENTAL DEPARTMENT">DENTAL DEPARTMENT</option>
<option value="HEALTH">HEALTH</option>
<option value="DENTAL ANATOMY">DENTAL ANATOMY</option>
<option value="SCIENCE OF DENTAL MATERIALS">SCIENCE OF DENTAL MATERIALS</option>
</select></div>
<div class="form-group"><input type="text" id="specialization_reg" name="specialization_reg" placeholder="Specialization" required="required" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="chamber_name_reg" name="chamber_name_reg" placeholder="* Chamber Name" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="chamber_availability_reg" name="chamber_availability_reg" placeholder="Chamber Availability" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="chamber_address_reg" name="chamber_address_reg" placeholder="* Chamber Address" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="education_reg" name="education_reg" placeholder="* Education" class="form-control color-default rounded-pill"></div>
<div class="form-group"><input type="text" id="bmdc_number_reg" name="bmdc_number_reg" placeholder="* BMDC Number" class="form-control color-default rounded-pill"></div>
<div class="form-check mb-2"><input type="checkbox" id="location_reg" name="location_reg" value="1" class="form-check-input"><label for="exampleCheck1" class="form-check-label" style="color: white;"> Take my current location as my chamber
location </label></div>
</div>
</div>
</form>Text Content
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