QR – Doctor Information Collection Form

Doctor Information Collection Form

Full Name of Doctor *

Qualification(s) *Please enter doctor's qualification, separated by commas

Specialisation *Please enter doctor's medical specializations, separated by commas.

Short Bio of Doctor *

Attach Doctor Photo *Supported File Types (.jpg | .png)

No file chosen

Attach a photo of the doctor's visiting card or prescription pad *Supported File Types (.jpg | .png | .pdf)

No file chosen

Clinic / Associated Hospital Name *

Consultation Time *If the clinic / Hospital has multiple slots, separated by commas

Clinic / Hospital Address *

Mobile Number *(for Appointment/Enquiries)

Services Provided (Maximum 5) *Please enter clinic / hospital services, separated by commas

Choose your preferred QR Code Format *Printed Posters (A5 Size Sticker)Durable PVC QR Stand

Provide the social media linksPaste the social medial links of Facebook, Instagram, Linkedin, Youtube, etc,.. Seperated by commas

Additional Information (If any)

For Internal Purpose Only

Division *

Diabetes Care Division

Zone *

Headquarters - South Zone *

Territory - Chennai Division *

Territory - Coimbatore Division *

Territory - Madurai Division *

Territory - Calicut Division *

Territory - Trivandrum Division *

Territory - Hyderabad Division *

Territory - Vijayawada Division *

Territory - Bangalore Division *

Territory - Hubli Division *

Headquarters - East Zone *

Territory - Kolkata Division *

Territory - Siliguri Division *

Territory - Cuttack Division *

Headquarters - West Zone *

Territory - Mumbai Division *

Territory - Pune Division *

Territory - Ahmedabad Division *

Territory - Indore Division *

Headquarters - North Zone *

Territory - Delhi-1 Division *

Territory - Delhi-2 Division *

Territory - UP Division *

Territory - Ludhiana Division *

KCRM/ MR Name *

Gastro Care Division

Zone *

Headquarters - South Zone *

Territory - TN / Coastal AP Region - SF *

Territory - Rest Of TN Region - SF *

Territory - Telengana Region - SF *

Territory - Karnataka Region - SF *

Territory - Kerala Region - SF *

Headquarters - East Zone *

Territory - West Bengal Zone - SF *

Territory - Kolkata Region - SF *

Territory - Bhubaneswar Region - SF *

Headquarters - West Zone *

Territory - Maharasthra Zone - SF *

Territory - Mumbai Region *

Territory - Gujarat Region - SF *

Headquarters - North Zone *

Territory - Delhi Zone - SF *

Territory - Delhi Region - SF *

Territory - Kanpur Region - SF *

KCRM/ MR Name *

Chronic Care Division

Zone *

Headquarters - South Zone *

Territory - Chennai Division-1 *

Territory - Chennai Division-2 *

Territory - Salem Division *

Territory - Madurai Division *

Territory - Kerala *

Territory - Ernakulam Division *

Territory - Trivandrum Division *

Territory - Hyderabad Division *

Territory - Vizag Division *

Territory - Bangalore Division *

Territory - Gulbarga Division *

Headquarters - East Zone *

Territory - Kolkata Division *

Territory - Siliguri Division *

Territory - Odisha Division *

Territory - Raipur Division *

Headquarters - West Zone *

Territory - Mumbai Division-1 *

Territory - Mumbai Division-2 *

Territory - Pune Division *

Headquarters - North Zone *

Territory - Delhi Division *

KCRM/ MR Name *

Prima Division

Zone *

Headquarters - Bangalore Region *

Territory - Bangalore North *

Territory - Mysore *

Territory - Bangalore South *

Headquarters - Hubballi *

Territory - Hubballi *

Territory - Kalaburagi *

Headquarters - Pune *

Territory - Kolhapur *

Territory - Pune *

Headquarters - Nagpur *

Territory - Nagpur *

Territory - Akola *

Headquarters - Chennai *

Territory - Chennai West *

Territory - Chennai North *

Territory - Cuddalore *

Territory - Coimbatore *

Headquarters - Madurai *

Territory - Madurai 2 *

Territory - Tirunelveli *

Territory - Salem *

Headquarters - Ernakulam *

Territory - Ernakulam *

Territory - Calicut *

Territory - Trivandrum *

Headquarters - Bhubaneshwar *

Territory - Bhubaneshwar *

Territory - Berhampur *

Territory - Jeypore *

Headquarters - Cuttack *

Territory - Cuttack *

Territory - Sambalpur *

Territory - Balasore *

Territory - Ranchi *

Headquarters - Raipur *

Territory - Raipur *

Territory - Bilaspur *

Territory - Indore *

Territory - Satna *

Headquarters - Hyderabad *

Territory - Karimnagar *

Territory - Kurnool *

Territory - Hyderabad *

Headquarters - Vijayawada *

Territory - Vizag *

Territory - Vijayawada *

Headquarters - Varanasi *

Territory - Varanasi *

Territory - Prayagraj *

Territory - Lucknow *

Headquarters - Kolkata Division *

Territory - Kolkata Division *

Headquarters - Siliguri *

Territory - Siliguri *

KCRM/ MR Name *