eReferral | Clinic Registration

Enter Your Clinic Information

Clinic Name

Clinic Email

Clinic Phone Number

Which hospital were you referred from?

Address

Clinic Location

Search or drag the marker to set your clinic's exact location. Address fields will auto-populate.

Postcode

City

State/Province

Country

Enter Your Account Details

Email

Password

Confirm Password

Doctor's Full Name

ID Type

ID Number Please select ID type first

Medical Registration Number Enter MMC No. (Malaysia), NSC No. (Brunei), or STR No. (Indonesia)

Mobile

Select plan as per your requirement

Basic A simple start for start ups & Students ^$ 0 _/month

Standard For small to medium businesses ^$ 99 _/month

Enterprise Solution for enterprise & organizations ^$ 499 _/year

Enter your card information

Card Number

Name On Card

Expiry Date

CVV Code