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Doctor Tell us about you
Proforma for Individual Doctor
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Proforma for Diagnostic centre / Hospital
*
mandatory to fill
Personal Details :
Name:
*
Mailing Address:
*
City:
Pin Code:
Tel No:
*
Mobile:
E-Mail:
*
Qualification:
Specialty:
Practice Details:
Year of starting practice:
Type of practice:
Consulting
Diagnostic
Both
Hospital or nursing home attachment (if, yes, give details):
Yes
No
Are you on the panel:
Member - Panel of Insurance Medical Examiners (If yes, Please specify):
Any other Corporate Health Plan (If yes, Please specify):
Yes
No
Can you offer subsidized rates for corporate clients:
Yes
No
Are you aware of Managed Healthcare?
Yes
No
Will you be interested in being a part of Managed Healthcare?
Yes
No
Which of the following you possess? (Please tick):
ECG
TMT
2D ECHO
Holter
Pathology:
Own Lab
Collection Center
Auto analyzer
Cell counter
Radiology:
X-ray
Sonography
Endoscopy services
Laparoscopic Surgery
Computer:
Yes
No
Any other facilities Please specify:
If spouse / child a medico - give details:
I understand this information is confidential and will be only used by INCHES for pre qualification database purposes.
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