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Fill in the following details to register as ASP Panel. (* compulsory fields)
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