Name of VLE
Date of Birth
Contact Number
Email Address
Education Qualification and brief background on why did you became VLE
Full Address of the Center
Do you have healthcare background? If so what? (DMLT or BMLT or Other)
Nearest City and Distance
Approximate population within 5km radius of the center
Near by medical facilities (Please name all that are present)
Date when center started
Facilities at the center currently
Footfalls at the center
August July June
Healthcare footfalls if any
August July June
Issue faced or If any other information you want to provide?

I hereby declare that I have provided the information accurately to best of my knowledge and Medi360 reserves the right to verify the same during the due diligence exercise if my center is selected for due diligence.