PHFAoG New Member Registration

New Member Registration

Facility Type:

Name of Facility:

Ownership Type:

Region:

Branch:

District:

Town/City:

Brief Location:

Postal Address:

Digital Address:

Facility Email:

Primary Contact:

Hefra Registration No.:

Practitioner In Charge:

NHIS Accredited:

Yes

No

NHIS Accreditation Date:

NHIS Next Expiry Date: