Testing Centre Partner Registration

Centre Name:

Contact Person:

Email:

Phone No.:

Country:

City:

State:

ZIP Code:

List of diagnostic services offered:

Do you perform full medical scans?
Yes No

Do you have MRI facilities?
Yes No

Interested in collaborating with MD Global Care?
Yes No

How did you hear about MD Global Care Platform?

Are you currently sending referrals?
Yes No

Types of facilities or products you refer:

Any other information you would like to provide: