Medical Provider Onboarding

Please complete all sections carefully. Your information helps us verify and onboard your facility efficiently.

Section 1 of 5

Personal & Contact Information

Full Name *

Provider Type *

Country *

City / Region *

Job Title / Role

Mobile Number *

🇱🇾 +218 ▼

🇱🇾 Libya +218

🇪🇬 Egypt +20

🇹🇳 Tunisia +216

🇲🇦 Morocco +212

🇯🇴 Jordan +962

🇩🇿 Algeria +213

🇸🇦 Saudi +966

🇦🇪 UAE +971

🇬🇧 UK +44

🇺🇸 USA +1

Work Email Address *

Preferred Contact Method

Phone Email WhatsApp

Full Address

Section 2 of 5

Credentials & Licensing

License / Registration Number *

Issuing Authority *

License Expiry Date *

Years of Experience

Are you currently practicing?

📎 Required Documents

License Copy *

Upload your valid professional license

📄

Click to uploadاضغط للرفع

PDF, JPG, PNG — max 5MB

Commercial Registration *

Upload your facility commercial registration

🏢

Click to uploadاضغط للرفع

PDF, JPG, PNG — max 5MB

Price List *

Upload your services price list for your city/region

💰

Click to uploadاضغط للرفع

PDF, JPG, PNG, Excel, Word — max 10MB

Section 4 of 5

Practice / Facility Information

Facility Name *

Facility Type *

Facility License Number

Number of Staff

Operating Days

Operating Hours

Accept Walk-ins?

Website / Social Media

Google Maps Link

Section 5 of 5

Insurance & Billing

Accept Insurance?

Accept Cash?

Accept Card / Online?

VAT Registration Number

Account Holder Name *

Bank Name

IBAN Number

✓

Application Submitted!

Thank you. Our team will review your information and get in touch within 2–3 business days.

Medical Provider Onboarding

تأهيل مزودي الخدمة الصحية

Application Submitted!

تم تقديم الطلب!