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* Mandatory Fields |
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| Registration Form |
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| Name of the Nursing Home/Hospital *
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Enter first name |
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| Upload Photo *(only .jpg, .jpeg and .png files allowed & file size < 500KB) |
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| Postal Address |
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| Line 1 * |
Line 2 * |
Enter Address |
Enter emailInvalid format
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| District * |
City * |
Enter city |
Enter city |
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| State * |
Pincode * |
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| Email * |
Phone * |
Enter Address |
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| Mobile No. * |
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Enter Address |
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Name of the owner 1 *
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Name of the owner 2 *
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Name of the doctor responsible *
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Enter first name |
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| Degree of the Doctor * |
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*(.jpg, jpeg and .pdf files allowed with file size < 500KB) |
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Upload Degree of the Doctor |
| M.C.I. Reg. no. of Doctor * |
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*(.jpg, jpeg and .pdf files allowed with file size < 500KB) |
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Upload M.C.I. Reg. no. of Doctor |
| Affidavit No. * | |
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*(.jpg, jpeg and .pdf files allowed with file size < 500KB) |
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Upload Affidavit No. |
| Date of establishment / start N. H./ Hosp * |
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| N. Home / Hospital detail * |
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