If you would like to join our Provider Network, please fill in the form below. (Please note: All fields marked with an asterisk (
*
) are mandatory)
Name of the Provider:
*
Provider Type:
*
---Select Provider Type---
Clinic
Hospital
Laboratory
Pharmacy
Others
Contact Person:
*
Address:
Country:
*
--Select Country--
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antarctica
Antigua And Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bidoun
Bolivia
Bosnia And Herzegovina
Botswana
Brazil
British Indian Ocean Territory
Brunei Darussalam
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Congo, The Democratic
Cook Islands
Costa Rica
Cote Divoire
Croatia
Cuba
Cyprus
Czech Republic
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands (Malvinas)
Faroe Islands
Fiji
Finland
France
French Guiana
French Polynesia
Gabon
Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guinea
Guinea-Bissau
Guyana
Haiti
Heard Island And Mcdonald Islands
Holy See (Vatican City State)
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Installations In International Waters
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jordan
Kazakhstan
Kenya
Kiribati
Korea
Kosovo
Kuwait
Kyrgyzstan
Latvia
Lebanon
Liberia
Libyan Arab Jamahiriya
Liechtenstein
Lithuania
Luxembourg
Macao
Macedonia, The Former Yugoslav Republic Of
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova, Republic Of
Monaco
Mongolia
Montserrat
Morocco
Mozambique
Myanmar
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Northern Mariana Islands
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn
Poland
Portugal
Puerto Rico
Qatar
Reunion
Romania
Russian Federation
Rwanda
Saint Helena
Saint Kitts And Nevis
Saint Lucia
Saint Pierre And Miquelon
Saint Vincent And The Grenadines
Samoa
San Marino
Sao Tome And Principe
Saudi Arabia
Senegal
Serbia And Montenegro
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
South Africa
South Georgia And The South Sandwich Islands
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard And Jan Mayen
Swaziland
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Trinidad And Tobago
Tunisia
Turkey
Turkmenistan
Turks And Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
United States Minor Outlying Islands
United States Of America
Uruguay
Uzbekistan
Vanuatu
Venezuela
Viet Nam
Virgin Islands, British
Virgin Islands, U.S.
Wallis And Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
City:
--Select Location--
Abu Al Bukhoosh
Abu Dhabi
Abu Musa
Ahmed Bin Rashid Port
Ajman
Al Ain
Al Dhafra
Al Fujairah
Al Hamriyah
Al Jazeera Port
Al Jeer Port
Ar Ruways
Arzanah Island
Aweer Terminal
Das Island
Deira
Deira
Dibba
Dubai
Dubai World Central Apt
Esnnad
Fateh Terminal
Free Port
Habshan
Hamriya Free Zone Port
Hulaylah Terminal
Indooroodilly
Jebel Ali
Jebel Ali Free Zone
Jebel Dhanna
Jumayrah
Kalba
Khalidia
Khor Al Fakkan
Masfut
Mina Khalid
Mina Khalifa/Abu Dhabi
Mina Rashid Port
Mina Saqr
Mina Zayed/Abu Dhabi
Minhad
Mirfa
Mubarek Terminal
Mubarras Island
Musafa
Mussafah
Offshore Fujairah
Port Rashid
Rak Khor Port
Rak Maritime City
Ras Al Khaimah
Ras Al Khor
Ras Zubbaya (Ras Dubayyah)
Ruwais Port
Sadiyat Island
Sharjah
Sharjah Icd
Sila
Sir Bani Yas
Steven Rock Terminal
Suez
The Palm Jumeirah
Umm Al Nar
Umm Al Quwain
Vopak Horizion Terminal
Yas Island
Zirku Island
Phone:
*
Fax:
EMail:
*
Confirm EMail:
*
E-Claim Link Id/HADD License/MOH:
*
Attachment :
*
(Allowed: .jpg, .jpeg, .png, .gif, .pdf)
(If any E-claim Link Id document/
HAAD License document/MOH documents)
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