Hospitals Registration

Hospital Name

Hospital Email Address

Hospital Phone Number

Hospital Website

Hospital Address

Consultation Type

Hospital Logo (Max Size 2MB)

SERVICES	ACTUAL FEE	ELITHE VIGOR DISCOUNT (%)		GST (%)	NET TOTAL
SERVICES	ACTUAL FEE	EXPECTED (%)	APPROVED (%)	GST (%)	NET TOTAL
OP Doctor Charges / Visit
OP Service Treatment Charges / Day
IP Service Treatment Charges / Day
IP Doctor Charges / Day
IP Room Charges / Day
Nursing / Other Paramedics Service Charges / Day
Other Charges (Laboratory) / Day
Other Charges (Medications) / Day
Other Charges (Miscellaneous) / Day

HOD / Doctor Name

HOD / Doctor Specialization

HOD / Doctor Contact Number

HOD / Doctor Email ID

HOD / Doctor Appointment Days

MON TUE WED THU FRI SAT SUN

HOD / Doctor Appointment Duration

HOD / Doctor Consultation Fee

Total Number of Doctors in Hospital

Departments

Agreed EVPL Discount %

Upload Signature (Max Size 2MB)

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