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Diagnostic Laboratory Partner Registration Form Section 1 — Laboratory Information
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Laboratory / Company Name
*
Brand / Display Name
Type of Organisation
*
--- Select Choice ---
Diagnostic Laboratory
Pathology Laboratory
Diagnostic Centre
Hospital Laboratory
Imaging + Diagnostic Centre
Collection Centre
Year Established
Registered Office Address
*
Address Line 1
Address Line 2
City
--- Select state ---
Alabama
Alaska
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Ohio
Oklahoma
Oregon
Pennsylvania
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
State
Zip Code
Website
Section - 2 Contact Person
Authorised Contact Person Name
*
Designation
*
--- Select Choice ---
Owner
Founder
Director
Lab Manager
Mobile Number
*
WhatsApp Number
*
Email
*
Section 3 — Registration & Verification
Business Registration Type
First Choice
Second Choice
Third Choice
Proprietorship
Partnership
LLP
Private Limited
Public Limited
Trust / Society
Hospital / Institutional
Other
NABL Accreditation
Yes
No
Section 4 — Laboratory Services What services do you offer?
3 Business services
Checkboxes
First Choice
Second Choice
Third Choice
Blood Tests
Urine Tests
Stool Tests
Hormonal Tests
Diabetes Tests
Thyroid Tests
Liver Function
Kidney Function
Lipid Profile
Vitamin Tests
Allergy Tests
Cancer / Tumour Markers
Microbiology
Histopathology
Molecular Diagnostics
Genetic Testing
Health Packages
Other
Section 5 — Declaration
I hereby confirm that the information provided above is accurate and that the laboratory is authorised to provide the diagnostic services listed on the SurgiBid platform. I understand that SurgiBid may verify the information and documents submitted before activating the laboratory profile.
Consent
I Agree
Name
Designation
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