
APPLICATION FOR LICENSE
FOR HEALTHCARE ESTABLISHMENTS
Healthcare Establishments are required to complete this form as per the requirements of the provisions of Punjab Healthcare Commission Act 2010.
Incomplete forms will not be entertained.
Provision of incorrect information/documents will result in rejection of the Application.
Return the completed form to:
Directorate of Licensing & Accreditation,
Punjab Healthcare Commission
Office # 1 & 2, 4th FloorShaheen Complex, 38-Abbot Road, Lahore
For further information, please visit our web site : www.phc.org.pk
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GENERAL INFORMATION |
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HEALTHCARE SERVICE PROVIDER |
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Name: |
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Qualification:
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CNIC Number:
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Registration No. PMDC/ PNC/ NCH/ NCT:
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Mailing Address:
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Town:
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City: |
District: Punjab |
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Telephone (landline & mobile)
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Fax: |
Email: |
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HEALTHCARE ESTABLISHMENT |
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Name: |
Date of establishment at present Location: (Day/Month/Year)
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Previous Name (If any): |
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Mailing Address: |
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Town: |
City: |
District: Punjab |
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Telephone:(landline & mobile) |
Fax: |
Email: |
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TYPE OF ORGANISATION |
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Type of Ownership (please check the appropriate box) |
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Government |
Others |
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£ District Government |
£ Sole Proprietary |
£ Voluntary Non- Profit |
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£ Provincial Government |
£ Partnership |
£ Association |
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£ Federal Government |
£ Corporation |
£ Limited Liability Company (Private) |
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£ Autonomous Institution |
£ Trust |
£ Limited Liability Company(Public) |
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£ CMH/ Cantonment Hospital |
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If incorporated or registered, date of incorporation/No & organization it is registered with: |
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License No. (if any): |
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TYPE OF HEALTHCARE ESTABLISHMENT (please check the relevant box) |
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£ Teaching £ Non-Teaching £ Single Specialty (please specify): _____________________________________________________ £ Multiple Specialty £ Others GP Clinic/ Homeopath/ Hakim/ Lab/ Radiological or Imaging/Maternity or Nursing homes/ Dental clinic/ Cosmetic Surgery/ Laser Clinic/ If any other please specify: _____________________ |
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EXTERNAL VALIDATION |
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List all applicable external certificates, licenses, accreditation and similar Awards/ Certificate £ Agency________________________________ £Award ___________________________________ £ Agency________________________________ £Award ___________________________________ £ Agency________________________________ £Award ___________________________________ £ Agency________________________________ £Award____________________________________
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SERVICES PROVIDED BY THE HEALTHCARE ESTABLISHMENT |
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Check the type of services that are provided, Attach additional pages if necessary |
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Check if provided |
Service |
Check if provided |
Service |
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Medical |
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Surgical |
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£ |
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Burns |
£ |
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Cardiac |
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£ |
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Cardiology |
£ |
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Day surgery |
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£ |
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Communicable diseases |
£ |
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ENT |
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£ |
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Dermatology |
£ |
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Facio-maxillary |
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£ |
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Ear Nose & Throat |
£ |
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General |
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£ |
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Endocrinology |
£ |
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Gynae |
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£ |
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Gastrointestinal |
£ |
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Head and neck |
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£ |
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General |
£ |
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Joint replacement |
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£ |
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Genetics |
£ |
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Neurosurgery |
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£ |
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Genitourinary |
£ |
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Obstetric |
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£ |
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Geriatrics |
£ |
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Ophthalmological |
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£ |
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Haematology |
£ |
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Orthopaedic |
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£ |
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Hepatology |
£ |
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Paediatric surgery |
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£ |
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Neonatology |
£ |
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Plastic and reconstructive |
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£ |
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Neurology |
£ |
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Thoracic |
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£ |
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Oncology |
£ |
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Transplant |
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£ |
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Ophthalmology |
£ |
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Urology |
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£ |
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Paediatric |
£ |
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Vascular |
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£ |
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Pain management |
£ |
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£ |
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Palliative care |
£ |
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Others |
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£ |
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Pulmonary |
£ |
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£ |
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Renal |
£ |
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Additional Specialized Areas |
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£ |
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Renal dialysis |
£ |
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Blood Bank Services |
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£ |
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Rheumatology |
£ |
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Chiropody |
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£ |
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Reproductive |
£ |
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Chiropractic |
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£ |
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Other |
£ |
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Clinical Psychology |
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£ |
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£ |
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Nutrition |
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£ |
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Ambulance |
£ |
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Drug and Alcohol |
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£ |
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Community/home based care/immunization |
£ |
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General Dental |
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£ |
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Emergency |
£ |
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Inpatient Pharmacy |
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£ |
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Hospice |
£ |
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Laboratory – Biochemical |
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£ |
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Long Term Care Unit |
£ |
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Laboratory- Haematology |
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£ |
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Maternity |
£ |
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Laboratory –Histopathology |
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£ |
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Poly Trauma |
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Laboratory – Microbiology |
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Primary Care |
£ |
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Limbs and Prosthetics |
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Self Care Unit/Independent Living Facility |
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Orthognathic |
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£ |
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Psychiatry |
£ |
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Outpatient Pharmacy |
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Social Work |
£ |
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Periodontal |
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£ |
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Homeopathy |
£ |
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Physical therapy rehabilitation |
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£ |
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Allied Health |
£ |
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Prosthetic dental |
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£ |
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Speech therapy |
£ |
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Radiology/Imaging (diagnostic) |
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£ |
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Others |
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Radiology (therapeutic/intervention) |
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BED CAPACITY |
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Please read the explanatory note below. Indicate the total number of beds or treatment spaces actually set up and operational for patient care. If beds are unisex just indicate the total. |
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Number of Beds |
Male |
Female |
Total |
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1.
Medical |
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2.
Surgical |
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3.
Intensive Care |
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4.
Neonatal |
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5.
Operating Room |
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6.
Emergency Room |
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7.
Others (Please specify) |
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Total |
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OFFSITE LOCATIONS |
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£ YES £ NO |
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Name of Offsite Location: |
Type of Establishment: |
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Street Address: |
Telephone Number: |
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City: |
Number of Beds: |
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Services Provided: |
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STAFFING |
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Indicate number of full time (FT) and part time (PT) employees. Attach additional pages if necessary. |
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FT |
PT |
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1.
Board Membership (if applicable) |
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2.
Management |
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3.
Medical/Surgical Services |
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a.
Consultants |
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b.
Medical Officers |
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c.
House Officers |
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4.
Nursing |
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5.
Post Graduate Students/ Residents |
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6.
Support Services |
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7.
Allied Health |
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a.
LHV |
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b.
Technicians |
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c.
Midwives |
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d.
Physiotherapy Assistants |
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e.
Health aide |
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f.
Receptionist |
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8.
Pharmacy |
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9.
Therapists |
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a.
Physiotherapist |
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b.
Occupational therapist |
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c.
Speech therapist |
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10.
Volunteers |
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11.
Others |
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TOTAL Part Time |
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TOTAL Full Time |
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BUILDING PLANS & EQUIPMENTS |
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Building Plans |
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Do you have building plans? £ Yes Complete £ Yes but Incomplete £ No |
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Are building alterations and remodeling proposed in the next 5 years? £ Yes £ No |
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Number of floors: |
Residential Accommodation: |
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Number of Generators: |
Parking: |
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Number of Chillers: |
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List of Electro-Medical Equipment |
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List of Machinery |
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MANAGEMENT |
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CHIEF EXECUTIVE OFFICER (CEO)/INCHARGE/CHIEF OPERATING OFFICER (COO) |
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Name: |
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Title: |
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£Male £Female |
Begin Date:____/_____/_____ |
Status: £ Interim £ Acting £Permanent |
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Email: |
Phone Landline: |
Mobile: |
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Is the CEO/In charge/COO in charge of more than one facility? £Yes £No |
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If yes, Name of facility, address and city: _______________________________________________________
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Professional and Educational Qualifications of the CEO/ IC/ COO |
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PERSON INCHARGE IN ASBSENCE OF CEO / COO (SUBSTITUTE ADMINISTRATOR) |
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Name: |
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Title: |
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Contact Details: |
Telephone: |
Fax: |
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Professional and Educational Qualifications |
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MEDICAL DIRECTOR/MEDICAL SUPERINTENDENT (if different to A. above) |
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Name: |
£ Male £ Female |
Begin Date ____/____/____ |
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Title: |
Status: £ Interim £ Acting £ Permanent |
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Email: |
Landline/ Fax: |
Mobile: |
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Is the Medical Director in charge of more than one facility? £Yes £ No
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Name Of Facility, Address and City:
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Professional and Educational Qualifications |
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NURSE ADMINISTRATOR (DIRECTOR OF NURSING) |
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Name: |
Begin Date: _____/_____/______ |
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Email: |
Landline: |
Cell: |
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Professional and Educational Qualifications |
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PHARMACY INCHARGE |
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Name: |
Begin Date: _____/_____/______ |
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Email: |
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Cell: |
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Professional and Educational Qualifications |
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LABORATORY INCHARGE |
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Name: |
Begin Date: _____/_____/_______ |
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Email: |
Landline: |
Cell: |
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Professional and Educational Qualifications |
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IV. OWNERSHIP |
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APPLICANT (OWNER) |
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Identify person(s) or business entity having the authority to direct the management or policies of the facility. |
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Name: |
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Street Address: |
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Mailing Address if different from Street Address: |
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Town: |
City |
Punjab |
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Telephone Number |
Fax Number: |
Email Address: |
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Name of Contact Person: |
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Title of Contact Person: |
Telephone Number: |
Cell: |
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Holding (what the owner owns) £ Operations £ Building £Land |
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CHANGE OF OWNERSHIP |
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List the previous owner’s name |
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Name – Previous Owner:
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SUBSIDIARY / PARENT INFORMATION |
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Is the applicant a subsidiary company, either wholly or partially owned by another organization or business? £ YES £ NO If yes, provide the following information. |
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Legal Business name – Parent Company: |
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Doing Business As: |
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Type of Ownership: |
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Mailing Address: |
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City |
Telephone: |
Contact Person:
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ATTESTATION
I, the undersigned, do hereby solemnly affirm and declare that the information provided above is true and correct to the best of my knowledge and belief and that nothing has been concealed therefrom. I also state that if any false or incorrect information is provided to the Commission, it may result in rejection of my application for license and I may also be found liable to pay fine to the Commission.
Signature |
Name of Applicant:
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Date Signed:
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Designation:
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Explanatory Notes
In the absence of an official establishment email address, please insert the email address of the Establishment CEO.
If the Healthcare Establishment has obtained certification/accreditation from any recognized entity such as ISO, kindly state with the date of award/certification.
This section is divided into three thematic areas. Kindly check the relevant box(es) for your Healthcare Establishment in each of these categories.
This section pertains to offsite locations like collection centers, offsite labs, immunization centers, blood banks, practice locations etc. An offsite location is not located or occurring at the site of a particular activity. Add additional pages if necessary.
For the purposes of fulfilling the requirements of the Punjab Healthcare Commission Act 2010, the Healthcare Establishment must maintain an updated database of all doctors, nurses, technicians and assistants and other medical support staff. Please attach additional sheet with the names, qualifications, PMDC/Nursing Council registration numbers, email addresses and contact numbers of all medical staff.
Residential Accommodation pertains to the staff and doctors residing either on the premises of the healthcare establishment or a facility in arrangement with the healthcare establishment.
Provide details of the owner and Head of Management of Healthcare Establishment. An owner for the purposes of the licensing form shall be a person that possesses the exclusive right to hold, use, benefit-from, enjoy, convey, transfer, and otherwise dispose of an asset or property or an executive who has the principleresponsibility for a process, program, or project.
Appendix A: Information of Full Time Staff
NAME |
DESIGNATION |
REGISTRATIONNUMBER |
CONTACT INFORMATION |
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Appendix B: Information of Part Time Staff
NAME |
DESIGNATION |
REGISTRATIONNUMBER |
CONTACT INFORMATION |
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Appendix C: List of Electro-Medical Equipment
Sr. No. |
Name of Equipment |
Type |
Model |
Functional |
Non-Functional |
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