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Application History
New
Registration Details
Upload Suppotive Documents
Inward No
Facility Type :
Hospital / Maternity Home Details
Facility Name
Location
Area/Street
Ward
Ward 1
Ward 2
Ward 3
Zone
Landmark
Pincode
Tel.(Landline)
Mobile
E-mail
Website
Registration Year
Select Year
1
2
3
4
5
Registered Office Details
Location
Area/Street
Ward
Zone
Landmark
Pincode
Tel.(Landline)
Mobile
E-mail
Ownership Details
Date of Commencement
Ownership
If Any
Name of Owner
Only M.B.B.S ?
Select
Yes
No
Nationality of Owner
Pan No.
M.B.B.S Reg. No.
Location
Area/Street
Ward
Zone
Landmark
Pincode
Tel.(Landline)
Mobile
E-mail
Owner's Date of Birth
Incharge Person Details (Residential Address Only)
Name of Incharge
Designation
Education Qualification
If Any
Location
Reg.No.
Area/Street
Ward
Zone
Landmark
Pincode
Tel.(Landline)
Mobile
E-mail
Details of Services Offered by Hospital
Providing Patient Care
System of Medicine Offered
Name & Other Particulars(of services,etc) of Nursing Home in respect of Which the Registration Applied for
Providing Diagnostic Services(Laboratory)
Laboratory Other
Providing Diagnostic Services(Diagnostic)
Diagnostic Other
Whether the Nursing Home/Premises used or are to be used for purposes other than Nursing Home.
Choose Options
Yes
No
Give Details.
Is the Laboratory Maintaining Internal & External Quality monitoring
Choose Options
Yes
No
Not Applicable
Other Details
Drinking Water Facility?
Choose Options
Yes
No
Electricity Available ?
Choose Options
Yes
No
Patient Record Keeping Facility?
Choose Options
Yes
No
Fire Safety Made/Not?
Choose Options
Yes
No
Not Applicable
Name of Medical Practitioner/Staff Displayed or Not ?
Choose Options
Yes
No
Name of Visiting Medical Practitioner Displayed or Not?
Choose Options
Yes
No
Place for Nursing Staff Accomodation Available or Not?
Choose Options
Yes
No
Details of Infrastructure
Area of Facility(Sq.Ft.)
Total Area(Sq.Ft.)
Constructed Area(Sq.Ft.)
A.Out Patient Department
Add New Specialitywise Distribution of OPD Clinic
Sr #
Speciality
Speciality Desc.
No.of Rooms
Remarks
Action 1
Action 2
B.IN Patient Department
Add New Specialitywise Distribution of beds
Sr #
Speciality
Speciality Desc.
No.of Rooms
No.of Beds
Remarks
Action 1
Action 2
Total No.of Beds
Details of Registrations
Registered in Gumasthadhara ?
Registered for PC-PNDT Act ?
Select
Yes
No
Not Applicable
Registered for MTP & Family Planning Surgeries ?
Select
Yes
No
Not Applicable
Registered for GPCB/Bio Waste ?
Select
Yes
No
Not Applicable
Municipal/Property tax Paid ?
Pay Property Tax
Professional Tax Paid ?
Pay Professional Tax
Canteen Available ?
Select
Yes
No
Not Applicable
Food Licence No.
Food Registration
Emergency Exit Map Displayed or Not?
Select
Yes
No
Not Applicable
Registration Date
Details of Staff
Add New Staff
Sr #
Category
Category Desc.
Name of Staff
Qualification
Qualification Desc.
Registration No
Nature of Services
Action 1
Action 2
Details of Un-Registered / UnQualified / Foreign Nationality Nursing Staff
Any Un-Registered/UnQualified Staff/Dr in Nursing Home
Add New Unregistered Staff
Sr #
Category
Category Desc.
Name
Nature of Service
Action 1
Action 2
Any Foreign Nationality Person/Staff employed in Nursing Home
Add New Foreign Nationality Person/Staff
Sr #
Category
Category Desc.
Name
Nationality
Nationality
Nature of Service
Action 1
Action 2
Document Upload Details
Note : Only PDF file allow. Document file size should be less than or equal to 5 MB each.
Doc id
Document Name
Mandatory
File
Doc Name
Action 1
Status
I have read and agree to abide by the terms and Condition.
Terms & Conditions
Submit Request
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Out Patient Department
Sr.No.
Specialty
No.of Rooms
Remarks
×
In Patient Department
Sr.No.
Specialty
No.of Rooms
No.of Bed
Remarks
×
Staff Details
Sr.No.
Category
Name of Staff
Qualification
Qualification
Registration No
Nature of Service
×
Un Registered/Unqualified Staff/Dr Details
Sr.No.
Category
Name
Nature of Service
×
Foreign Nationality/Staff Employed in Nursing Home
Sr.No.
Category
Name
Nature of Service
Nationality
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