Provider Type* Select Provider TypeMedical CentreHospitalDental ClinicPharmacyLab & RadiologyLab OnlyRadiology OnlyHome HealthcarePhysiotherapy CentreRehabilitation Centre
Provider Name (As per the Trade License)*
Eclaimlink / Riayati / Shafafiya ID*
Provider Group Name
(These details will be shared with the Customer for Appointments / Communications)
Landline*
Email ID*
Country*
Emirates* Select EmirateAbu DhabiDubaiSharjahAjmanFujairahRas Al KhaimahUmm Al QuwainOther Country
Location / Area*
Address*
PO Box Number
Google Map URL
Working Hours*
(Please mark and fill in all your available Specialties and Services)
Specialities* General PractitionerInternal MedicineObstetrics & GynaecologyPaediatricianOrthopaedicOtolaryngology (ENT)DermatologySurgeonNeurologyUrologyPulmonologyGastroenterologyNephrologyRheumatologyG P DentalOphthalmologyPsychiatryPsychologyAyurvedicHomeopathyDietitianNONE of the ABOVE
Any Other Specialist
Services Available* PhysiotherapyIn-house LabIn-house X-rayIn-house USGCTMRIPET ScanSpeech TherapyAudiologyPharmacyNONE of the ABOVE Any Other Service
(The following details will be used for official communication)
Insurance Department
Name
Designation
Mobile Number
Email ID
Operations Department
Authorized Signatory
(The following details will be used only for official purposes)
Trade License
Emirate
Select EmirateAbu DhabiDubaiSharjahAjmanFujairahRas Al KhaimahUmm Al QuwainOther Country
License Number
Issuing Date
Expiry Date
Attach License Copy
Regulatory License
Regulatory Authority
Select Regulatory AuthorityDHADOHMOHOther Country
VAT Certificate
Tax Registration Number
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(Please fill out the correct details)
Beneficiary Name*
IBAN*
Account Number*
Swift Code*
Bank Name* Select Bank NameAbu Dhabi Commercial Bank – ADCBAbu Dhabi Islamic Bank – ADIBAjman BankAl Hilal BankBank of BarodaBank of SharjahCommercial Bank of Dubai – CBDCommercial Bank International – CBIDubai Islamic Bank – DIBEmirates Islamic Bank – EIBEmirates NBDFirst Abu Dhabi Bank – FABHSBCMashreq BankNational Bank of Fujairah – NBNational Bank of Umm Al Quwain – NBQRAK BankSharjah Islamic Bank – SIBStandard Chartered BankUnited Arab BankWIO BankOther
If none of the above:
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Branch Address*
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