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E-Registration
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Registering Doctor
Doctor's Name
*
Doctors's MCR Number
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Doctor's Email Address
*
Doctor's Mobile Number
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Referred By / Promo Code (Indicate N.A. if not referred by anyone)
Are you registering for Business or Personal use?
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Business
Personal
Both
Are you an existing customer of POM?
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No
Business/Clinic Information
Name of Business/Clinic
*
Postal Code
*
Business Full Address
*
Street Address
Contact Details for Administrative and Billing Purposes
Name of Contact Person
*
Business Registration Number
Email Address
*
Office Number
*
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T&C
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