Hospital Registration Details
Hospital Name*  
Hospital Type*  
State*  
District*  
Taluk*  
City*  
Address*  
Pin Code*    
Land Mark*  
LandLine No.*    
Fax No.  
E-mail ID*    
Approximate distance  from NH and SH
NH Name*  
Hospital to NH Distance* km   
SH Name*  
Hospital to SH Distance* km   
Sital Area (Sq. ft.)  
Built up Area (Sq.ft.)  
Latitude deg  min  sec 
Longitude deg  min  sec 
Year of Establishment*    
Empanelled with VAS*  
Applicant Details
Name*  
Designation*  
Mobile Number*    
Aadhaar Number  
Email-ID*    
Registered Mobile Number1*
(for SMS alert and Patient Registration)
     
Registered Mobile Number2    
Registered Mobile Number3    
Username*  
Password*  
Password must contain atleast one Uppercase character,one Lowercase character,one number and one of special character @#$%^*/.
Confirm Password*    
Type the Image text*  
   
* mark indicates mandatory fields.