MediConfirm | Register Radiology Center

Radiology Center Name

License Number

Address

Country

State

City

Telephone

Cell Phone

File Format should be PDF,JPG, JPEG or PNG

License

File Format should be PDF,JPG, JPEG or PNG

Accreditation Certificate

First Name

Middle Name

Last Name

National ID

Association Card Number

Gender

Date of Birth

Address

Same as Radiology Center

Country

Telephone

Cell Phone

File Format should be PDF,JPG, JPEG or PNG

Picture ID

File Format should be PDF,JPG, JPEG or PNG

License to Practice

File Format should be PDF,JPG, JPEG or PNG

Association Id Card

Signed By

By submitting this form I approve MediConfirm Terms and Conditions, Privacy Policy and EULA

I hereby certify, under penalty of perjury, that the foregoing information is true and correct.