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Register Hospital

*  Mandatory Fields

Add Hospital Details

Name of the Hospital* :
Address 1st Line*:
Address 2nd Line:
State *:
City* :
Phone No 1 *
(Country Code / City Code / Number)
:     
Phone No 2
(Country Code / City Code / Number)
:     
Hospital Fax Number:
Name of the Hospital Director *:
Director Mobile No*
(Country Code / City Code / Number)
:   
Director E-Mail ID (or)
Hospital’s Official *
(Mail will be sent to this email id)
:
Secondary E-Mail ID:
Hospital Website Address
eg:(http://www.sample.com/)
:

Category

Cadaver * :
Live* :
Corneal * :
Is your Transplant Registration Licence Active?:
Licence Expiry Date* :
Cetificate Number* :
Name of the Transplant Coordinator* :
Tx Mobile No (Numbers Should Be Accessible 24/7) *:  

Tx Email ID *:

Consultants Details

Name of Consultants and Mobile No
Consultant1*:
 Mobile No*:   
Consultant2*:
 Mobile No*:   
Consultant3:
 Mobile No:   
Consultant4
 Mobile No:   

(Please note that two of these numbers should be accessible 24/7)