Pharmacy Registration Form

Basic Information

Pharmacy Name *

Please enter the pharmacy name.

Owner Name *

Please enter the owner's name.

Email Address *

Please enter a valid email address.

Mobile Number (with OTP Verification) *

Mobile number must be between 9 and 15 digits.

WhatsApp Number

Password *

Password must be at least 8 characters long.

Store Logo

Legal & Licensing Details

Pharmacy License Number *

Please enter the license number.

Upload Registration Certificate (if applicable)

Store Location & Address

Full Address *

Please enter the full address.

Country

State *

Please select a state.

District *

Please select a district.

Area

Street Name *

Please enter the street name.

Building Name *

Please enter the building name.

Google Map Location / GPS Coordinates

Operational Details

Set opening hours for each day (like Google My Business). Mark "Closed" for days you don't operate.

Day	Closed	Hours
Monday	Closed	–
Tuesday	Closed	–
Wednesday	Closed	–
Thursday	Closed	–
Friday	Closed	–
Saturday	Closed	–
Sunday	Closed	–

Home Delivery

24/7 Service

Products & Services

Types of Medicines Sold

Medical Equipment / Surgical Items

Prescription Required

Online Orders Accepted

Payment Methods Accepted

Cash

Card

Wallet

Additional Documents

Store Front Photo

Owner’s ID Proof

Website URL (Optional)

Social Media Links (Optional)

Verification & Compliance

I confirm that the information provided is accurate and I comply with all legal and regulatory requirements.

You must confirm the declaration.

I agree to the Terms & Conditions and Privacy Policy.

You must agree to the terms and conditions.