Hospital or Center or Institute

FACILITY DETAILS:

Facility Name (English):

:اسم المؤسسة او المستشفى (اللغة العربية)

Facility Type:

:(في حالة المستشفيات او المراكز الخاصة يكتب خاصة) المستشفى تابعة لأي هيئة

Detailed Facility Address (English):

:العنوان التفصيلي (اللغة العربية)

Please Attach Location:

Phone Number:

Any additional INFO you would like to add:

CLINIC DETAILS:

Clinic Name (English):

:اسم العيادة (اللغة العربية)

Working hours:

Phone Number:

Number of all practicing physicians in the clinic:

Number of IBCLCs:

Any additional INFO you would like to add:

CONTACT PERSON INFORMATION:

Name (English):

:الاسم باللغة العربية

Email Address:

Personal Phone Number:

National ID Number:

I am an IBCLC from:

IBCLC ID Card Number:

Position of the contact person in the submitted Clinic:

Main Medical Specialty:

Titles(Certificates & Affliations):

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