Join DR. Khokha as a E-Medi Plaza

Personal Information

First Name *

Last Name *

Email Address *

Phone Number *

🇮🇳 +91

Address

State *

District *

Block / Sub-district *

Village *

Pincode

Country *

Share your clinic's GPS location. The admin will review the location and configure the geofenced service area.

Latitude *

Longitude *

Location access is requested only when you select “Use my current location”. The service radius will be configured by the admin.

Please upload relevant documents to support your application (PDFs, images accepted, max 2MB each):

Documents

Business license, certificates, team credentials

Referral Code Earn HB Coins (Optional)

Optional. If a friend or agent referred you, add their code — both of you will earn HB Coins after approval.

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