Product Registration Form
Online registration will help us service you better.
Customer Data
Customer Name *
Customer Email *
Official Email
Customer Contact # *
Official Mobile/Landline
Customer Designation *
Account Name *
Hospital / Institution Name
Account Address *
Hospital / Institute Address
Product Data
Product Make *
Supplier Name
Product Category *
Product Model *
Product Serial No. *
Product Accessories *
Standard Peripherals Received on Delivery (as applicable)
Product Installation Date *
DD/MM/YY
Product Installation Department *
Example: ICU/CCU/NICU/OT/Emergency (Within Hospital Premises)
Product Status *
Working/Not Working-Remarks
Channel Data
Local Dealer Name *
Company Name
Submit
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