1RupeeClinic

Partner Onboarding

Diagnostic / Hospital Name *

Take Photo *

Contact Person Name *

Last Name

Diagnostic / Hospital Address *

Street Address

Street Address Line 2

Street Address

City

State / Province

Postal / Zip Code

Geolocation *

Phone Number *

Enter OTP *

Upload Rate List *

Referral Percentage *

Signature *

Signature will be saved as an image.