Provider Registration

Clinic / Shop onboarding

Create your Clinic / Shop account

Fields marked * are required. Optional fields may be skipped. If a required field is missing, the form will move to it automatically.

Category *Shop / Business Name *WhatsApp Number *Enter only a valid 10-digit WhatsApp number.Email *Example: name@example.com

Address

District *Block *Village / City *Nearest Landmark

Or click the Google map to place your shop pin.

Google Maps is unavailable until the administrator adds a browser API key.

Latitude *Longitude *

Shop Front Image *Choose an existing image from Gallery/Photos.Or take a live photoUse Camera for a new photo. One image source is required.JPG, PNG or WebP only; maximum 5 MB. The final optimized image is saved at 120 KB or less.

ZoomDrag the preview to position the square crop. The server securely revalidates and optimizes it.

Password *LowConfirm Password *