Diagnostic Centre & Pathology Lab for Blood Tests In <?= $cityname ?>

Centre Registration Form

Section 1: Centre Information

Centre Name

Please enter a valid Centre Name.

Centre Address

Please enter a valid Centre Address.

City

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State

Please select a State.

Pincode

Please enter a valid 6-digit Pincode.

Contact Number

Please enter a valid 10-digit Contact Number.

Email ID

Please enter a valid Email ID.

Section 2: Owner / Applicant Details

Full Name of Applicant

Please enter a valid Name without special characters.

Designation / Role

Please select a Designation.

Mobile Number

Please enter a valid 10-digit Mobile Number.

Email Address

Please enter a valid Email Address.

ID Proof Type

Please select an ID Proof Type.

Upload ID Proof

Please upload your ID Proof.

Section 3: Centre Infrastructure

Separate Collection Room?

Yes

Please select an option.

Refrigerator for Sample Storage?

Yes

Please select an option.

Bio-medical Waste Disposal?

Yes

Please select an option.

Upload Centre Photographs

Please upload at least one photograph.

Section 4: Staff Information

Number of Phlebotomists

Please enter a valid number.

Training Certificates Available?

Yes

Please select an option.

Upload Staff Qualification Certificates

Please upload at least one certificate.

Section 5: Bank & Payment Details

Bank Name

Please enter a valid Bank Name.

Account Number

Please enter a valid Account Number.

IFSC Code

Please enter a valid IFSC Code.

Upload Cancelled Cheque / Passbook Copy

Please upload a valid file.

Section 6: Declaration

I hereby declare that the above information is true and correct to the best of my knowledge. I agree to follow the compliance and operational standards as guided by the company.

You must agree to the declaration.

Applicant Name

Please enter a valid Name without special characters.

Date of Application

Please enter a valid date.

Signature (Upload)

Please upload a valid file.