Clinic / Diagnostic Center Registration

Clinic / Diagnostic Center Name *

Please provide clinic name.

Center Base Address *

Please provide center address.

Center's Owner Name *

Please provide owner name.

Center's Phone Number *

Please provide a valid phone number.

Center's Owner Email ID *

Please provide a valid email.

Center's Operator Name *

Please provide operator name.

Center's Operator Phone Number *

Please provide a valid phone number.

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