REGISTRATION FORM FOR DOCTORS

Choose File

Full Name-

M/s/ Dr.-

Father’s/Husband’s/Owner’s Name-

Contact Number-

Alternate Contact Number-

E-mail Id-

Date of Birth-

Name of Clinic/Nursing Home/Hospital/Lab-

Address

PIN-

City-

State-

Qualification-

Name of the Association enrolled if any-

Medical Registration Number-

Existing policy or membership with any insurance company (Yes/No) (If yes, name of the insurance policy-

Sum insured-

Any claim experience-

Any claim experience -If yes; please share the brief description about the nature and stage of litigation (this detail is required if you wish to have our membership for non-medico legal cases as well)-

If you wish to take membership for any colleague doctor operating from your clinic, please share his/her name with educational qualification-

If you wish to have membership for any other qualifiedstaff/nurse/compounder/health worker working in your clinic? If yes, please share the details-

Nominee-

Any other information-

DATE

DRAWN ON

CHEQUE NO./DD/NO

AMOUNT

NOTES

As per Services of Medins Legal LLP I hereby voluntarily declare to be a member of Medins Legal LLP for which I deposit Rs. for year/s and I am quoting my details above.

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