Meeseva Allopathic Private Medical Care Registration Health Application Form

Meeseva Allopathic Private Medical Care Registration Health Application Form

Download Meeseva Allopathic Private Medical Care Registration Health Application Form

Allopathic Private Medical Care Registration Application Form

Allopathic Private Medical Care Registration Application Form
Hospital Name*:___________________ ______
Door No /H.No*: ___________________
_____________________________Location/Locality*: ___________________
Mandal*:_____________________ Village*: ____________Pin Code*: _____________
Own/Rent*: __________Lease Period In Years*: __________ Hospital Estd Date*: _______t Name*: _________________ Correspondent/PRO/ Administrator Mobile No*:
________________________Correspondence Email Id: _____________________________
Description of Open Area*: __________________Description of Constructed Area*: ___________________________________________________
Financial Position Brief Description*: __________________________________________
Other Information Brief:_______________________________________________________
Strength of Beds: __________________Hospital Category*:__________________________
Services Offered (Yes/No) :
Basic Service*:
Yes/No
Specialty Service*:
Yes/No
Super Specialty Service*:
Yes/No
Diagnostics Service*:
Yes/No
Pediatric Service*:
Yes/No
Physio Therapy Service*:
Yes/No
Labor
Room with Pediatric Care Facility *:
Operation Theatre *:
Yes/No
Diagnostic Facility Including Clinical Laboratory I
maging Facility *:
No of Facilities Available *: __________________________
Delivery Type*:
Manual
Society Details:
Society/Trust Name: _______________________Address:_________________________
Society Registered Date: ___________________________________________________