iHealth Pay™ - Exclusive Payment gateway for Doctors, Labs, Pharmacies

HealthCare Provider Sign-up

Organization Details :

Organization Name*

GST Number

Phone *

Account Email*

Fax

Address-Line1 *

Address-Line2

Country *

State *

City *

ZIP/ Postal Code *

Account Administrator Details :

Last Name / Family Name *

First Name *

Prefix

Mobile Number *

Email *

Bank Account Details :

Account Number

Confirm Account Number

IFSC code

Account Holder Name

Country

Account Number *

Routing Number *

Account Name (name as it appears on the account)*