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Goverment of Madhya Pradesh
Department of Public Health & family Welfare
कीओस्क के लिए अति महत्वपूर्ण सूचना
पोर्टल फीस के सम्बन्ध में महत्वपूर्ण सूचना
कीओस्क द्वारा ऑनबोर्ड फॉर्म भरने के लिए आवेदक से कोई शुल्क नहीं लिया जाएगा ।
स्कैनिंग प्रति पेज रु. 3/- अतिरिक्त आवेदक द्वारा देय होगा ।
एम. पी. ऑनलाइन द्वारा कीओस्क को ऑनबोर्ड फोरम भरने हेतु रु. 80/- प्रति फॉर्म कमीशन स्वरुप दिया जावेगा माह के बाद दिया जाएगा।
Form A:
On Board Registration
Fields Marked with * are mandatory
Applicant Details
Facility Details
Centre Details
Equipment Details
Employee Details
Requirement(Rule-3)
Declaration
Summary
Type of Clinic
Government
Private
As per serial no/s. 3,7,9 in prescribed Form-A
Type of Facility to be registered:
*
Genetic Clinic
Genetic Counselling Centre
Genetic Laboratory
Imaging Centre
Ultrasound Clinic
As per serial no/s. 4,5,6 in prescribed Form-A
Centre Name:
*
Address:
*
District:
*
Select
Agar
Alirajpur
Anooppur
Ashoknagar
Badwani
Balaghat
Betul
Bhind
Bhopal
Burhanpur
Chhatarpur
Chindwara
Damoh
Datia
Dewas
Dhar
Dindori
Guna
Gwalior
Harda
Hoshangabad
Indore
Jabalpur
Jhabua
Katni
Khandwa
Khargone
Mandla
Mandsaur
Morena
Narsinghpur
Neemach
Panna
Raisen
Rajgarh
Ratlam
Rewa
Sagar
Satna
Sehore
Seoni
Shahdol
Shajapur
Shivpuri
Shoerpur
Sidhi
Singroli
Tikamgarh
Ujjain
Umaria
Vidhisha
Tehsil:
*
Select
Village/City:
*
Select
Pin Code:
*
Mobile No:
*
Telephone No.:
Email Id:
*
Fax No.:
Type of Ownership:
*
--Select--
Co-operative
Company
Individual
Others
Partnership
Type of Institution:
*
--Select---
Government Hospital
Nursing home
Others
Stand Alone Clinic
Upload Documents
Electricity Bill/Rent Agreement etc)
Address Proof of the centre :
*
Jpg image (10kb to 200kb) only
Scan copy uploaded shall be self-attested
Type of Ownership
Proof :
*
Jpg image (10kb to 200kb) only
Scan copy uploaded shall be self-attested
Type of Institution
Proof :
*
Jpg image (10kb to 200kb) only
Scan copy uploaded shall be self-attested
As per serial no/s. 8 in prescribed Form-A
Make
*
Model
*
Type of Mobility
*
Portable
Static
Year of Manufacture
*
Serial No.
*
New/Buy-Back of Product
*
Select
1980
1981
1982
1983
1984
1985
1986
1987
1988
1989
1990
1991
1992
1993
1994
1995
1996
1997
1998
1999
2000
2001
2002
2003
2004
2005
2006
2007
2008
2009
2010
2011
2012
2013
2014
2015
2016
2017
2018
2019
2020
2021
2022
2023
2024
Buy Back
New
Upload Invoice
*
PDF only (10 kb to 900kb)
Scan copy uploaded shall be self-attested
As per serial no/s. 10 in prescribed Form-A
Salutation
*
Name
*
Category
*
Qualification
*
Experience
*
--Select--
Dr.
M/s
Mr.
Mrs.
Ms.
Prof.
Shri
On Board Registration
Registration/Renewal
--Select--
Any Other
Gynaecologist
Lab Technician having B.Sc. Degree in Biological Sciences
Lab Technician having Degree/Diploma in medical laboratory course with at least one year experience
Medical Geneticist
Paediatrician having four week experience
Paediatrician having six months training
Pelvic Ultrasonography: Level one for M.B.B.S Doctors
Radiologist: MD in Radiology / DMRD in Radiology
The Fundamentals in Abdomino
Year
Select
0
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
31
32
33
34
35
36
37
38
39
40
41
42
43
44
45
46
47
48
49
50
Month
Select
0
1
2
3
4
5
6
7
8
9
10
11
12
M.P State Medical Council Number
*
Aadhar No:
*
Upload M.P State Medical Council Number Certificate
*
PDF only (10 kb to 900kb)
Scan copy uploaded shall be self-attested
Upload Proof of qualification of the employees
*
PDF only (10 kb to 900kb)
Scan copy uploaded shall be self-attested
As per serial no/s. 11,13 in prescribed Form-A
State whether the Genetic Counselling Centre/Genetic Laboratory/Genetic Clinic/Ultrasound Clinic/Imaging Centre* qualifies for registration in terms of
requirements laid down in Rule 3:
Yes
DECLARATION
PRE-CONCEPTION AND PRE-NATAL DIAGNOSTIC TECHNIQUES
(PROHIBITION OF SEX SELECTION) RULES, 1996
I,
--Select--
Dr.
M/s
Mr.
Mrs.
Ms.
Prof.
Shri
Select Relation
Daughter
Father
Mother
None
Sibling
Son
Wife
of
--Select--
Dr.
M/s
Mr.
Mrs.
Ms.
Prof.
Shri
aged
years resident of
working as (indicate designation)
in (indicate name of the Organization to be registered)
hereby declare that I have read and understood the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuses) Act, 1994 (57 of 1994) and the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuses) Rules 1996.
I, also undertake to explain the said Act and Rules to all the employees of the
in respect of which registration is sought and to ensure that Act and Rules are fully compiled with.
Date:
11/18/2024 2:59:58 AM
Place:
Name of authorized person:
Designation:
Applicant Details
Registration Type :
*
NHS Registration No:
*
Name of the Applicant:
Address:
District:
Tehsil:
Village:
PinCode:
Mobile:
Telephone No.:
NA
Email ID:
Fax No.:
NA
ID Proof
ID Proof No:
IS Medico:
State Medical Council Registration no.
Facility Details
Type of Facility to be Registered:
Genetic Clinic
Genetic Counselling Centre
Genetic Laboratory
Imaging Centre
Ultrasound Clinic
Center Details
Full Name of the Centre:
Address:
District:
Tehsil:
Village:
PinCode:
Mobile:
Telephone No.:
Email ID:
Fax No.:
Type of Ownership:
Type of Institution:
Equipment Details
Employee Details
Requirement(Rule-3)
State whether Centre qualifies for registration in terms of requirements laid down in Rule 3:
List of Enclosures:
Document Description
Attachment
Address Proof:
Electricity Bill/Rent Agreement etc) Address Proof of the centre:
Ownership Proof:
Institution Proof:
Equipment Invoice:
M.P State Medical Council Number Certificate:
Employee Certificate:
Declaration
PRE-CONCEPTION AND PRE-NATAL DIAGNOSTIC TECHNIQUES
(PROHIBITION OF SEX SELECTION) RULES, 1996
I,
of
aged
years resident of
working as (indicate designation)
in (indicate name of the Organization to be registered)
hereby declare that I have read and understood the Pre-natal Diagnostic Techniques (Regulation and Prevention of Misuses) Act, 1994 (57 of 1994) and the Pre-Natal Diagnostic Techniques (Regulation and Prevention of Misuses) Rules 1996.
I, also undertake to explain the said Act and Rules to all the employees of the
Label
in respect of which registration is sought and to ensure that Act and Rules are fully compiled with.
Date:
Place:
Name of Authorized Person:
Designation:
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