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Subject

All fields are required (^*).

I would like to update the following clinic details:

Current clinic name ^*

Current clinic license number ^*

Informant Name ^*

Informant Designation ^*

Informant contact number ^*

Type of Clinic ^*

MedicalDental

Please select the field(s) you are updating

Date for changes to take effect ^*

New clinic name

New clinic license number

Reason for new clinic license number

Others

Clinic Owner

Address

Floor

Unit

Block

Building

Street

Postal Code

Telephone

Email Address

Fax

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