Registration Form

*  Mandatory Fields
*  If Phone less than 8 no add 0 before
Hospital Details
Name of the Hospital*
Address 1st line*
Address 2nd line
State*

City*
Phone No.*  -  -
EMail ID*
(Mail will be sent to this email id)
WebSite Address
Director / Medical Superintendent of Hospital
Name*
Phone*  -  -
Cell Number *  -
E-mail *
Transplant Coordinator
Name*
Cell Number of Co-ordinator *  -
E-mail *
Surgeon's Details
Surgeon 1
Name*
E-mail*
Cell Number *  -
Surgeon 2
Name
E-mail
Cell Number  -
Surgeon 3
Name
E-mail
Cell Number  -
Surgeon 4
Name
E-mail
Cell Number  -
Physician's Details
Physician 1
Name*
E-mail*
Cell Number *  -
Physician 2
Name
E-mail
Cell Number

 -
Types of transplant being done in your hospital
Transplant License for organs
Liver *
Kidney *
Heart *
Lungs *
Details of the person, who fills this form
Name*
E-mail address*
Cell Number *  -






The Indian Transplant Registry is a product developed for Indian Society of Organ Transplantation.

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