REGISTRATION FORM FOR HOSPTIAL NURSING HOME
Name of Medical Director/Owner/Partner-
Name of the Hospital/ Nursing Home
Address of the Hospital/ Nursing Home-
PIN-
City-
State-
E-mail Id-
Contact Details-
Year of Establishment-
Number of Hospital Staff/ General Physicians/ Nurses/ Workers-
Number of beds-
Number of ICU beds-
State in which Hospital/ Nursing Home is registered accredited by-
Facility for international patients? –
Approximate number of in-patients/OPD/ Admitted Patients/ Surgeries in last six months-
Are the Doctors/Nurses/Technicians working for you-?
Duly licensed in accordance with the Medical acts of and other prevalent laws-
Members of Medical Association/Council-
Specify all the facilities available-
X-Ray, Scanning, Pathology
Whether persons operating these are qualified
State the number of employees (including visiting Doctors) in act of following classifications)
General Physician
Plastic Surgeon
Dentists
Pharmacists
Technician
Nurses
Trainees
Voluntarily Worker
Other, Please specify
Specialist including-
EYE/ENT
Pathologist
Cardiologist
Radiologist
Anaesthetists
Gynaecologist
Dental Surgeon
Paediatrician
Ambulance facility available-
Facility for international patients?
Whether food is supplied by you to the patients? If yes, specify whether it is prepared by you of supplied by outsiders. If supplied by you, Please specify the measures taken for maintenance of kitchen and other supervisory measures.
Do you supply medicines to the patients?
Existing policy or membership with any insurance company (Yes/ No) If yes, name of Insurance Company-
Name of Policy-
Sum insured-
Any claim experience-
Any pendency or litigation relating to medical or personal-
If yes, please share the brief description about the nature and stage of litigation (this detail is required if you wish to have our membership for non-medico legal cases as well)-
If you wish to take membership for any colleague doctor/ operating from Nursing Homes/Hospitals, please share their name with educational qualification-
If you get the membership for any other qualified Staff/Nurse/Compounder/Health Worker working in your Nursing Home/ Hospitals? If yes, please share the details-
DATE
DRAWN ON
CHEQUE NO./DD/NO
AMOUNT
NOTES
As per Services of Medins Legal LLP I hereby voluntarily declare to be a member of Medins Legal LLP for which I deposit Rs. for year/s and I am quoting my details above.
