Healthcare Partner Registration
Old CID Road, Dist.#7, Montserrado ¦ (231) 776028506 ¦ MediAdmin@medibridgeaccess.com
Section 1: Type of Facility
Pharmacy
Hospital
Clinic
Section 2: Basic Information
Facility Name
*
Company Webpage
License Number
Date of Establishment
Type of Ownership
Private
Government
NGO
Other
Type of Ownership:
Section 3: Contact Information
Business Address:
City / County:
Contact Person:
Position / Title:
Phone (Primary):
Please enter a valid phone number.
Phone (Alternate):
Please enter a valid phone number.
Email Address:
example@example.com
Section 4: Service Details
Operating Hours:
Specialties or Services Offered:
Do you offer emergency services?
YES
NO
Do you provide home delivery?
YES
NO
Preferred Partnership Type:
*
Referral Collaboration
Prescription Fulfillment
Delivery Partner
Health Service Provider
Other
Area(s) of Coverage:
Section 6: Regulatory & Compliance
Licensed by (Authority Name):
License Expiry Date
-
Month
-
Day
Year
Date
Attach Copy of License:
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Section 7: Agreement & Authorization
I hereby certify that the information provided above is true and correct. I authorize MediBridge Access Int’l to verify and list my facility as a partner on its platform.
Facility Representative Signature:
Point of Contact - Partnership
Contact Name
*
Phone Number
*
Email Address
*
example@example.com
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Should be Empty: