Register as Partner Doctor | CarePlus Program

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Register as Partner Doctor

Please answer the following questions accurately.
Your information will be used as a basis for your enrollment.

Personal Information

First Name

Last Name

Email

Mobile Number

PRC License Number

Specialization

Clinic Information

Primary Office

Hospital/ClinicPlease select 'Other' if you can't find your hospital/clinic in the list.

Clinic Hours

Clinic Contact Number

Street Address

Province

Select province

City

Select city

Secondary Office (Optional)

Hospital/ClinicPlease select 'Other' if you can't find your hospital/clinic in the list.

Clinic Hours

Clinic Contact Number

Street Address

Province

Select province

City

Select city

Referral

Full NamePlease provide the full name of the Medical Representative or Product Specialist who referred you to the program.