Provider Name *
Provider Type *
Category *
Address 1 *
Address 2
Postcode / City *
State *
Country
Tel *
Fax *
Email Address *
Name of Person In-Charged *
Maximum consultation charges (Day)*
Maximum consultation charges (Night)*
Payment credit terms
Operation Hours *
Remarks

YES
Monday Closed
Tuesday Closed
Wednesday Closed
Thursday Closed
Friday Closed
Saturday Closed
Sunday Closed
Public Holiday Closed
Item Price From Price Till
Medication Charges for Treatments below
FLU/URTI
Cough/Sore throat
Bronchitis
Gastritis
Gastroentritis / Diarrhea
FEVER (DENGUE, VIRAL, PROLONGED)
Nausea/Vomitting
Headache/Migraine/Giddiness
Eczema/Dermatitis
Backache
Burns & Scalds
Injury & Cuts
Asthma
Sinus
Abdominal Pain
Charges for Medical Procedures below
X-ray/Scan/ECG
Ultra Sound
Dressing
Nebulizer
Surgery
Charges for Lab Test below
Blood Test
Blood Sugar Level Test
Urine Test
Cholestrol
Charges for Dental Treatments below (For Dental Clinic used only)
Amalgam Scalling
Single surface
Two surface
Three surface
Dentine pins per pin
Composite Filling
Single surface
Two surface
Three surface
Dentine pins per pin
Extraction
Anterior Teeth
Premolars
Molars
Primary Teeth Anterior
Primary Teeth Posterior
Surgical extraction
Removal of Embedded Tooth
Removal of Impacted Tooth
Root Canal Therapy
Single Root
Two Roots
Three Roots
Aplcectomy Anterior Tooth
Pulpectomy
Crowning
Porcelain
Porcelain Puse to Non-Precious
Plastic Crown
Scalling & Polishing
X-Ray (PA Only)
Denture
Consultation
Medication
Other

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