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Hospital Administrator / Contact Person Details *

Title *

First Name *

Last Name *

Designation *

Mobile No. *

Email ID *

Head of the Department*

Title *

First Name *

Last Name *

Designation *

Mobile No. *

Email ID *

Organization Details*

Name of the Organization * (Please ensure the name is entered exactly as required on the participation certificate)

Country *

State *

City *

Address *

Pincode *

Category *

Zone *

Total Operational Bed Strength *

Does the Healthcare Facility have a valid Fire NOC from the Fire Safety Department / Approved Third Party? *

Does the Healthcare Facility have a valid Pollution Control Board (PCB) License? *

Does the Facility have a valid NABH Certification/Accreditation? *

Number of Endoscopy Units *

Average Number of Gastro Endoscopy Cases per Month *

Number of Doctors in the Gastroenterology Endoscopy Department *

Number of Trained Endoscopy Nurses *

Number of Trained Endoscopy Technicians *

Upload Organization Logo *

Invoice Details*

GSTIN Applicability *

PAN No. *

Fee details*

Payable Amount + 18% GST

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