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Hospital Empanelment Application

Name of the Hospital / Diagnostic Centre

Address

Email Address

Phone Number

Fax Number

Type of Ownership

Name of the Contact Person

Email Address of Contact Person

Phone/Mobile Number

Whether the Hospital/Diagnostic Centre is recognized/Under panel of any Govt./Non-Govt. Organization? If Yes (please specify)

Please Specify

What are the Facilities available?

Number of In-house Doctors?

Number of Visiting Specialists/Consultants?

What are the Laboratory facilities available?

What are the Imaging Services available?

Any other Information:

Minimum 4 characters