Brandwin Care Connect Registration -

Hospital / Clinic Name *

Type of Facility *ClinicMulti-specialty ClinicHospitalNursing Home

Specialty / Department *

Year of Establishment *

Registration Number / License Number *

Issuing Authority (Medical Council / Local Authority) *

Street Address *

Apartment, suite, etc

City

State/Province

ZIP / Postal Code

Country

Google Map Location Link (optional)

Name of Doctor / Authorized Person *

Designation *DoctorMedical SuperintendentAdministratorOwner / Partner

Phone *

WhatsApp Number

Email Address *

Number of Doctors Practicing *

Average Daily Patient Volume *

Working Days *

Clinic / Hospital Timings *

Primary Contact Number for Patients *

Secondary Contact Number for Patients

Type of Support Required (Select all that apply) *Patient Call AssistanceAppointment Coordination SupportEnquiry HandlingMissed Call / Enquiry RecoveryFront Desk Workload Support

Preferred Language for Patient Communication *EnglishMalayalamTamilOther

Expected Start Date *

Upload file *Clinic / Hospital Registration Certificate

Upload file *Doctor Registration Proof (Medical Council ID)

Upload file *GST Certificate (if applicable)

Authorized Signatory ID Proof *AadhaarPANPassport

Upload file *Authorized Signatory ID Proof

Declaration *Engagements are initiated only through direct interaction. Brandwin CareConnect operates as a specialized healthcare communication support initiative and not as a public call center.I hereby confirm that the information provided above is true and accurate to the best of my knowledge. I understand that Brandwin CareConnect provides non-clinical communication support only and does not offer medical advice or diagnosis. I agree to engage with Brandwin CareConnect through direct collaboration as per mutually agreed terms.

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