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General

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Registered Name *

Trade Name (if different)

Registration Date

License Number *

License Expiry Date *

Country of Registration

Saudi ArabiaUnited Arab EmiratesQatarKuwaitOmanBahrainLebanon

City of Registration

Type of Facility *

Standalone LaboratoryHospital-based LaboratoryDiagnostic CenterOther

Other Facility Type

Ownership

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Legal Entity Type *

Sole ProprietorshipPartnershipLimited Liability CompanyCorporationOther

Other Legal Entity Type

Name of Owner / Company *

Authorized Signatory *

Position / Title *

National ID Number *

Contact

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Lab Address *

Telephone *

Mobile

Direct Phone / Mobile

Email *

Website

Primary Contact Person *

Position

Contact Person Email

Operational

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24/7 Service Available

YesNo

Home Sampling Available

YesNo

Working Days *

• Monday
• Tuesday
• Wednesday
• Thursday
• Friday
• Saturday
• Sunday

Working Hours

Opening hour

Closing hour

Accreditation

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Accreditation Type

• ISO 15189
• CAP
• JCI
• Other
• None

Other Accreditation

Accreditation Number

Accreditation Valid Until

Services

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Routine Laboratory Services

• Hematology
• Clinical Chemistry
• Immunology
• Serology
• Microbiology
• Parasitology
• Urinalysis
• Hormonal Assays
• Histopathology
• Cytology
• Molecular Diagnostics / PCR
• Toxicology
• Genetic Testing
• Other

Other Routine Service

Specialized Services

Personnel

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Laboratory Director / Pathologist Name *

Qualification

License Number

Gallery

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Gallery

Upload Images

Upload up to 4 images

Upload

Billing

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Tax Registration Number / VAT No. *

Declarations

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The laboratory holds all valid legal licenses and approvals required to operate. *

YesNo

The laboratory complies with applicable health, safety, infection control, and waste disposal regulations. *

YesNo

The laboratory agrees to maintain confidentiality of patient and insurance information. *

YesNo

The laboratory agrees to abide by the insurance company’s policies, tariffs, claim submission requirements, and audit procedures. *

YesNo

The laboratory agrees to notify the insurance company immediately of any change in ownership, licensing, accreditation, address, or service scope. *

YesNo

Attachments

Attachments Previous Next

Copy of valid laboratory license

File name:

File size:

Copy of commercial registration

File name:

File size:

Copy of tax registration certificate

File name:

File size:

Copy of accreditation certificate(s), if any

File name:

File size:

List of authorized signatories

File name:

File size:

Copy of owner / authorized signatory ID

File name:

File size:

Name of Medical Director

List of services / test menu with prices

File name:

File size:

Sample report format

File name:

File size:

Professional indemnity / malpractice insurance, if applicable

File name:

File size:

Any other relevant document

File name:

File size:

Other document description

Final Declaration

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Authorized Signatory Name *

Title *

Date

Signature

Official Stamp

Submit