The details that you are going to submit, will be added to our online Directory of Palliative Centres across India. You are requested to fill up this form carefully with correct details so that we are able to provide people with correct information. Thank you.

 

Palliative Centre Details
  • Please fill up this form to submit details of a new Palliative Care Centre or to rectify details of an existing Palliative Care Centre.

    Please submit as much details as you can so that it helps people find the Palliative Centre.

    If you have information about more than one Palliative Care Centre, you can submit them one at a time. This means that this form can take information of one Palliative Care Centre at a time.

    Example: For submitting information about 3 Palliative Care Centres, please fill up and submit this form 3 times with information of 1 different Centre each time.
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  • Specify*Purpose
    I want to submit details of a new Palliative Centre to the directory.
    I want to correct details of a Palliative Centre present in the directory.
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  • Name*of Palliative Centre
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  • Name*of Governing Body
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  • Address*of Palliative Centre
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  • PIN*of Palliative Centre
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  • City / Town / Village*of Palliative Centre
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  • State / Union Territory*full name
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  • Phone Number*of Palliative Centre
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  • Email Address*of Palliative Centre
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  • Website Address*of Palliative Centre
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  • Name*of Contact Person 1
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  • Mobile Number*of Contact Person 1
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  • Name*of Contact Person 2
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  • Mobile Number*of Contact Person 2
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  • Upload*e-BrochureUpload
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    • Sender's Details
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    • Sender's Name*full name
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    • Sender's Email*valid email address
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