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Doctors

Doctors Under own clienic
individual Hospitals

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Contact Person Name:

Doctors Qualification:

Hospital Name:

Hospital Address:

State:

Place/ Area

pincode

E-mail Address

Mobile Number

PAN Card No:

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Order Type:

Drug Licence No/ Doctor Reg.No

Attach Drug license or state / MCI registration certificate in English

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Expiry / Renewal Date

GST No / Aadhar No :

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Reference Representative

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Directors

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Password

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Contact Person Name:

Doctors Qualification:

Hospital Name:

Hospital Address:

State:

Place/ Area

pincode

E-mail Address

Mobile Number

PAN Card No:

Attach file

Upload

Order Type:

Drug Licence No/ Doctor Reg.No

Attach Drug license or state / MCI registration certificate in English

Upload

Expiry / Renewal Date

GST No / Aadhar No :

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Upload

Reference Representative

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Stockist

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Stockist Name:

Stockist Address:

State:

Place/Area/Town

pincode

E-mail Address

Mobile no:

Landline number

Prop. / Partner:

Order Type:

PAN Card No:

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Drug Licence No:

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GST No:

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Special Request:

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Retailer-shop

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Password

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Contact Person Name:

Retail Medical Shop Name:

State:

Place/Area/Town

Medical shop Address:

E-mail Address

Mobile no:

Landline number

Order Type:

Drug Licence No:

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Upload

PAN No:

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Upload

GST No:

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Special Request:

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Multi-Speciality

Username

Password

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Contact Person Name:

Hospital Name:

Hospital Address:

State:

Place/Area/Town

pincode

E-mail Address

Mobile no:

Landline number

Order Type:

Drug Licence No:

Attach file

Upload

PAN No:

Attach file

Upload

GST No:

Attach file

Upload

Special Request:

Attach file

Upload

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Corporate

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Password

Confirm Password

Contact Person Name:

Hospital Name:

Hospital Address:

State:

Place/Area/Town

pincode

E-mail Address

Mobile no:

Landline number

Order Type:

Drug Licence No:

Attach file

Upload

PAN No:

Attach file

Upload

GST No:

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Upload

Special Request:

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Trust

Username

Password

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Contact Person Name:

Trust Hospital Name:

Trust Registration Number

NGO Scanned copy

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Trust Hospital Address:

State:

Place/Area/Town

pincode

E-mail Address

Mobile no:

Landline number

Order Type:

Drug Licence No:

Attach file

Upload

PAN Card No:

Attach file

Upload

GST No:

Attach file

Upload

Special Request:

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Visiting-doctor

Username

Password

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Contact Person Name:

Hospital Name:

Doctors Qualification:

Hospital Address:

State:

Place/Area/Town

pincode

E-mail Address

Mobile no:

PAN Card No:

Attach file

Upload

Order Type:

Drug Licence No:

Attach file

Upload

GST No:

Attach file

Upload

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Service-Hospital

Username

Password

Confirm Password

Contact Person Name:

Trust Hospital Name:

Trust Registration Number

Trust Hospital Address:

State:

Place/Area/Town

pincode

E-mail Address

Mobile no:

Landline number

Order Type:

NGO Scanned copy

Upload

Drug Licence No:

Attach file

Upload

PAN Card No:

Attach file

Upload

GST No:

Attach file

Upload

Special Request:

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Orders will be addressed within 1 -3 working day by our sales Team.
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Doctors

Directors

Stockist

Retailer-shop

Multi-Speciality

Corporate

Trust

Visiting-doctor

Service-Hospital

terms

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