General Details
Health care Unit Name: *Type:
Specialization:Level of Care
Plot Size(sq.m):No of Beds: *
Registered:Yes    No
Owner/Chief/Doctor:Certification
(ISO,NABL,JCI):
Address: *
Country:State:
District: *City: *
Pincode: *STD Code: *
Phone No: *Other Phone No:
Mobile No :FAX :
Email: *Website:
Landmark: *
Contact Person for TPA:Mobile No:
Email:
Contact Person for Billing:Mobile No:
Email:
Google Map:
Longitude:Latitude:
GooglePath:
Staff Details:
No of Resident Medical Officer:No of Full Time
Consultant:
No of Nursing Staff:No of Technician
Staff:
Do you practise
multiple tariff:
Yes  NoReason:
Bank Details:
Bank Name:Account No:
Branch Name:PAN No:
MICR No:IFS Code:
Cheque in favour
of:
Service TAX No: *
Remarks:Ref:
Upload:
Upload files( DOC and XLS Format )
Facilities: