Proforma for Diagnostic centre / Hospital

Institution Name: *

Mailing Address: *

City: State: Pin Code :

Tel No: * with STD code Fax: Mobile:

E-Mail: *

Ownership: Ownership Partnership
Pvt Ltd Trust Group

URL of Website:

No. of Hospital Beds:

ICU: Yes No
[If yes] No. of ICU Beds:

Operation Theatre: Yes No
[If yes] No. of OTs:

Do you have: Own Pathology Lab A Collection Center

If you have in-house path-lab kindly furnish the following details: System: Colorimeter Auto analyzer Semi Auto Analyzer

Cell Counter: Yes No
[If yes]: Coulter Bayer Sysmac

Others [specify]:

If your establishment is a Collection Centre. Details of the Main Lab:

Radiology: X-ray Sonography CT Scan
MRI Mammography OPG

Cardiology: ECG TMT 2D ECHO Holter
Colour Doppler Angiography Angioplasty Coronary Artery Bypass Surgery

Endoscopy: Yes No

Laparoscopic Surgery: Yes No

Joint Replacement: Yes No

Neuro Surgery: Yes No

Fertility Center: Yes No

Others [specify]:

Can you offer subsidized rates for corporate clients : Yes No

Available Consultants: Physician Cardiologist Surgeon
Pediatrician Gynec Ophthalmic
ENT Neurophysician Cancer unit

Other Specialities (Please specify):

I understand this information is confidential and will be only used by InCHES.

PS: Please attach a brochure / leaflet if available.