Thank you for ordering Medic Aid.

To enable us to send you the software with your specifications pre entered, please fill in the accompanying form, print it and send it to us with your cheque. You have to make the cheque / Draft in the name of AMLA MEDIQUIP payable in New Delhi or you may wait for our representative to contact you.

ESSENTIAL
 Print this page after entering details and attach it with your cheque / Draft
Basic Details
NURSING HOME NAME
DOCTOR NAME
PREFERRED PREFIX
ADDRESS
LOCALITY
PINCODE 
E-MAIL
PHONE NUMBER
OPTIONAL
FAX
WEB PAGE
TIMINGS