:: AURANGABAD MUNICIPAL CORPORATION |Certificates

Application form for Medical Termination of Pregnancy Hospital Registration

Applicant Details

Title of Applicant *

First Name*

Middle Name

Last Name*

Plot/ Flat No *

Name of the Building *

Name of the street *

Name of the area *

Pin Code *

Nearby landmark

Mobile No. *

Email *

Current Address of Applicant *

Category of Approved Place *

Pregnancy termination up to 12 weeks Pregnancy termination up to 24 weeks

Name of the place( in capital letters) *

Institute type *

Other Institute type*

State, if the following facilities are available at the place*

Full Address of Hospital*

Category A *

Gynaecological examination/labour table

Resuscitation equipment

Sterilization equipment

Facilities for treatment of shock, including emergency drugs

Facilities for transportation, if required

Category B *

An operation table and instruments for performing abdominal or gynaecological surgery

Drugs and parental fluid in sufficient supply for emergency cases

Anaesthetic equipment, resuscitation equipmemt and sterilization equipment

Hospital's Information Form

Full Name of the owner *

Phone no (Landline)*

Name of the Hospital *

Email ID *

Full Address of Hospital *

Institute type *

Other Hospital Institute *

Total number of beds *

Number of beds *

Deliveries conducted *

Yes No

Gynaecological Operation Conducted *

Yes No

Name of a Registered Medical Practitioner Employed in the Place & Their Experience in Gynaecology & Obstetrics Yes/No Mention Describe *

Yes No

Provide the facility of attachment on Letter head (Name of Dr., Qualification) *

If There is Full Time or Part Time Anaesthetist Working in the Place if So Give The Name, Qualification and Experience *

Provide the facility of attachment on Letter head (Name of Dr., Qualification) *

No. of Full Time Trained Assistant Working at This Place Yes/No. Mention Describe *

Provide the facility of attachment on Letter head (Name of Trained Asst., Qualification) *

State if Following Facilities are available at the Place and Give Their Details

An Operation Table And Instrument Performing Abdominal and Gynaecological Operations Yes/No. Mention Describe *

Yes No

Drugs And Parenteral Fluids Including Plasma Expanders In Sufficient Supply - For Emergency Cases Yes/No. Mention Describe *

Yes No

Anaesthesia Equipment Including Equipment For Anesthesia Resuscitation And Equipment For Blood Transfusion. Yes/No. Mention Describe *

Yes No

Oxygen Cylinders Available Yes/No. Mention Describe *

Yes No

PCPNDT Registation and Validity Yes/No. Mention Describe *

Yes No

Blood Bank Registration Yes/No. Mention Describe *

Yes No

Ambulance Service Available 24 Hours Yes/No. Mention Describe *

Yes No

Place:

Date:

Signature of the Hospital Owner with Stamp (On Letter Head)*

List of Document attachment for Gynaecologist (Scanned Original document )

Note: Upload Below Files only pdf, .jpg, .jpeg, .bmp etc.. Max upto 5MB

Gynaecologist Degree Certificate *

Additional Qualification Certificate *

Affidavit with Notary *

Aadhaar Card *

If Society/Trust, Registration Certificate from competent Authority *

List of Document attachment for Anaesthetist(Scanned Original document )

Note: Upload Below Files only pdf, .jpg, .jpeg, .png etc.. Max upto 5MB

Anaesthetist Degree Certificate *

Additional Qualification Certificate *

Affidavit with Notary *

Aadhaar Card *

If Society/Trust, Registration Certificate from competent Authority *

Hospital Documents

Note: Upload Below Files only pdf, .jpg, .jpeg, .png etc.. Max upto 5MB

Biomedical waste payment *

Nursing Home Certificate *

Blood Bank Undertaking Certificate *

O.T Swab 72 Hours, 48 Hours, 24 Hours *

Maharashtra Pollution Control Board Certificate (Valid)*

If Society/Trust, Registration Certificate from competent Authority *

Undertaking of Doctor who is Performing MTP on Letterhead of Hospital *

ONLINE CITIZEN SERVICES (75)

ऑनलाइन नागरिक सेवा (75)

Application form for Medical Termination of Pregnancy Hospital Registration

Applicant Details

Hospital's Information Form

List of Document attachment for Gynaecologist (Scanned Original document )

List of Document attachment for Anaesthetist(Scanned Original document )

Hospital Documents

ONLINE CITIZEN SERVICES (75)

ऑनलाइन नागरिक सेवा (75)

Application form for Medical Termination of Pregnancy Hospital Registration

Applicant Details

Hospital's Information Form

List of Document attachment for Gynaecologist (Scanned Original document )

List of Document attachment for Anaesthetist(Scanned Original document )

Hospital Documents

Upload listed files only .pdf, .jpg, .jpeg, .bmp (Max upto 5 MB)