Hospital Membership Registration

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Name of the Hospital

Address Line 1

District/ City

State

Pin Code

Phone

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: 5MB

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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