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Provider Name *
Provide Type *
Address Line 1 *
Address Line 2
City *
State *
Country *
Postcode *
Tel. No. *
Fax. No. *
Email Address *
Name of Person In-Charged *
Services & Facilities
Services Provided *
(Please list out)
With Internet Facilities
With X-Ray Facilities
Open 24 hours?
Operating Hours
Example
Monday *
Tuesday *
Wednesday *
Thursday *
Friday *
Saturday *
Sunday *
Consultation Charges
Day *
From
Till
Night
From
Till
Weekend & Public Holiday *
From
Till
Medication Charges for Treatments below
URTI / Sore Throat
From
Till
Cough / Cold
From
Till
Bronchitis
From
Till
Gastritis
From
Till
Gastroentritis / Diarrhea
From
Till
Fever
From
Till
Vommitting
From
Till
Headache / Migraine
From
Till
Dermatitis / Skin Disorder
From
Till
Backache / Bodyache
From
Till
Burns & Scalds
From
Till
Injury & Cuts
From
Till
Asthma
From
Till
Sinus
From
Till
Abdominal Pain
From
Till
Charges for Medical Procedures below
X-Ray
From
Till
Ultra Sound
From
Till
Dressing
From
Till
Nebulizer
From
Till
Minor Surgery
From
Till
Charges for Lab Test below
Blood Test
From
Till
Blood Sugar Level Test
From
Till
Urine Test
From
Till
Cholestrol
From
Till
Charges for Dental Treatments below (For Dental Clinic used only)
Scalling
From
Till
Cleaning
From
Till
Extraction
From
Till
Anesthetics or Antibiotic Drugs
From
Till
Fillings
From
Till
X-Ray
From
Till
Minor Surgery
From
Till
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