Clinic Registration Form

MyHealthcare Platform Services Agreement

Date:

Company/Clinic Name*

Company/Clinic Address*

Hospital/Clinic Display Name*

GST Number

PAN*

CIN Details

Registered Address*

City*

State*

Pin Code*

Country*

Hospital/ Clinic/ Coordinator Contact Number*

Hospital/ Clinic/ Coordinator Email

NO OF DOCTORS TO BE ONBOARDED

Title*

First Name*

Last Name*

Gender*

Date of Birth*

Mobile*

Speciality*

Designation*

Medical Registration Number*

Qualifications*

Years of Experience*

BANK DETAILS HOSPITALCLINICDOCTOR

Account Holder Name

Bank Name

Bank Account Number

Bank Address

MICR Code

IFSC Code

FEES: MyHealthcare Technologies Private Limited shall charge the Company the following fees to offer a solution for immediate deployment:

Summary	Charges
One Time Fee	Waived
SaaS for Video Consultation with EMR (0 to 300 consults per month) SaaS for Video Consultation with EMR (301 consults and above per month) (inclusive of video license platform, cloud hosting services and storage on AWS India)	INR 170 + GST INR 150 + GST
SaaS OPD Charges for OPD Consults (0 to 750 consults per month) SaaS OPD Charges for OPD Consults (751 consults and above per month)	INR 75 + GST INR 50 + GST

This MyHealthcare Services Agreement (“Agreement”) contains the Terms of Use on which the Company agrees to use the MyHealthcare Platform for providing healthcare consultation services to patients in India and abroad, and the terms and conditions on which MyHealthcare agrees to allow the Company to use the MyHealthcare Platform and provide the Services to the Company.

AUTHORISED SIGNATORY

Name*

Designation*

Mobile*

Email*

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