Instructions

  1. Please fill all the manadatory fields.
  2. Please upload 2 clinic photos (frontside of clinic & outside view).
  3. Please give the correct information of owner & person in-charge.
  4. Outpatient : Free & Validity : 365 Days,
    If you select for Outpatient, Please upload atleast 1 Outpatient photo.
  5. Pharmacy : Paid & Validity : 365 Days ,
    If you select for Pharmacy, Please upload atleast 1 Pharmacy photo.
  6. Laboratory : Paid & Validity : 365 Days ,
    If you select for Laboratory, Please upload atleast 1 Laboratory photo.
  7. Please upload 1 signature photo at the end of the form.

Form - 1

Clinic Information

Address

Upload


@if($clinic_photo1) @endif
@if($clinic_photo2) @endif

Contact

Form - 2

Owner's Information

Contact

Person-in-Charge Informations

Form - 3

Additional Informations

@if($ownership=="Others") @endif
@if($types_of_clinical_services=="Others") @endif

Please Choose Your Required Services

Reminder : Pharmacy & Laboratory both services has chargable

  Outpatient @error('types_of_clinical_establishment.0') {{ $message }} @enderror
Amount : Free
Validity : 365 Days
@if($clinicestopd)
@if($types_of_clinical_outpatient =="Others") @endif
@endif
  Pharmacy @error('types_of_clinical_establishment.1') {{ $message }} @enderror
@if($clinicestpharma)
@if($types_of_clinical_pharmacy =="Others") @endif
@endif
  Laboratory @error('types_of_clinical_establishment.2') {{ $message }} @enderror
@if($clinicestlab)
@if($types_of_clinical_laboratory =="Others") @endif
@endif

Other Informations

Clinic Registration Form

1. Name Of The Clinic : {{$clinic_name}}
2. Address : {{$clinic_address}}, {{$clinic_street}}, {{$clinic_city}}, {{$clinic_district}}, {{$clinic_state}}, {{$clinic_zip_code}}
3. Contacts Telephone No : {{$clinic_tel_no}}
Mobile No : {{$clinic_mobile_no}}
Email : {{$clinic_email_id}}
Website : {{$website_link}}
Co-ordinates : [{{$clinic_lat}}, {{$clinic_lng}}]
4. Owner Name : {{$owner_name}}
5. Address : {{$owner_address}}, {{$owner_street}}, {{$owner_city}}, {{$owner_district}}, {{$owner_state}}, {{$owner_zip_code}}
6. Contacts Telephone No : {{$owner_tel_no}}
Mobile No : {{$owner_mobile_no}}
Email : {{$owner_email_id}}
7. Person In Charge : {{$person_in_charge}}
8. Qualification(s) : {{$person_qualification}}
9. Registration No. : {{$registration_no}}
10. Name of Central/State Counsil (with which registered) : {{$name_of_council}}
11. Contacts Telephone No : {{$person_tel_no}}
Mobile No : {{$person_mobile_no}}
Email : {{$person_email_id}}
12. Ownership : {{$ownership}}
13. Ownership (Any Other) : {{$ownership_specify}}
14. System of Medicine : {{$system_of_medicine}}
15. Type of Clinical Services : {{$types_of_clinical_services}}
16. Type of Clinical Services (Any Other) : {{$types_of_clinical_services_specify}}
17. Type of Clinical Establishment
@foreach($this->cartarray as $key => $cart) @endforeach
Sl No. Particutlars Type Amount
{{$key+1}}. {{$cart['service_name']}} {{$cart['service_type']}}
{{$cart['service_type_other']}} 		INR {{$cart['service_cost']}}
Sub Total Amount INR {{number_format((float)$subtotal_amt, 2, '.', '')}}
CGST (9.00%) INR {{number_format((float)$cgst_amt, 2, '.', '')}}
SGST (9.00%) INR {{number_format((float)$sgst_amt, 2, '.', '')}}
Net Amount INR {{number_format((float)$net_amt, 2, '.', '')}}

Place : {{$place}}

Date Of Submit : {{$date_of_submit}}

Name : {{$signature_name}}

Signature :

@section('externaljs') @endsection