Hospital & Doctor Registration

* Fields marked * are required.

1. Hospital / Clinic Details

Name of Hospital / Clinic*

Type*

Hospital Clinic

We also provide diagnostic services

Registration No. (optional)

Hospital/Clinic Contact Number*

Address*

City / Taluka*

Email (optional)

2. Authorised Doctor Details

Doctor's Name*

Qualification

Specialty

Medical Registration No. (optional)

Mobile*

Doctor's photo (Optional)

JPG or PNG. It will be resized automatically.

3. Medical Facilities Available

Tick all that apply.

4. Concession for Aafiyah Card Holders

Enter the discount in percent. Enter 100 if the service is free.

OPD Consultation %

Hospitalisation %

Surgery %

Pathology Tests %

Medicines %

Other Services %

5. Declaration

We voluntarily agree to participate in the Aafiyah Health Card Project and provide the above concessions to registered Imam & Muazzin card holders of Akola District.

I agree to the declaration above.*

I consent to Flying Colours Education Foundation storing these details and using them for the Aafiyah Health Card Project.* Read our Privacy Policy

Hospital & Doctor Registration

Thank you! Your registration has been received.