PRIME OPERATING THEATRES & PROCEDURES ACCESS

Doctor's Name

Doctor's Email

Doctor's Phone number

SPECIALTY

SUBSPECIALTY

MEDICAL QUALIFICATIONS

COPY OF YOUR DEGREES OR DIPLOMAS

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OPERATING ROOM or CLINIC PROCEDURES

OPERATING ROOM or CLINIC PROCEDURES (OTHER)

DO YOU HAVE MEDICOLEGAL INSURANCE?*

EQUIPMENT NEEDED FOR OPERATING ROOM

EQUIPMENT NEEDED FOR OFFICE PROCEDURES

WILL YOU BRING YOUR OWN STAFF?*

PATIENT PAYMENT METHOD

DOCTOR'S FEE

MEDICOLEGAL INSURANCE DETAILS

FACILITY YOU WANT TO USE?*

ANYTHING ELSE YOU WANT US TO KNOW?