Hospital Membership Registration

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Name of the Hospital

State

District

City

Phone

Street Address with Pincode

Locality/Village/Tehsil

Contact Person Name

Landline Number

Mobile Number

Contact Person Email

Designation

Number of Beds in Hospital

Location of hospital

Type of Hospital

Photo Upload

Maximum file size: 516MB

Hospital Website Available?

CEO/Managing Director/Medical Superintendent

Mobile

Password

Eight characters minimum One lowercase letter One uppercase letter One number One special character

Confirm Password

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