Doctors

Name of Doctor *

Address *

Website *

Please provide below details*

Name Contact No. Email

Managing Director /
Director / Owner

Key concerned person - PR

/ Media / Marketing

GENERAL
Education Qualification *

● MBBS
● MS
● DNB (OB-GYN)
● MNAMS
● M.Med
● MRCOG
● FMB Fellow
● IVF
● Others

What is your total Practice Experience (in years) ? *

Are you associated with any hospitals / clinics as a consultant ? *

● Yes
● No
Please mention the number of hospitals/clinics that you are associated with as consultant *

Please Name them:

Are you associated with any medical college as a faculty *

● Yes
● No
 Please mention the number of medical colleges that you are associated with *

Please Name them:

INFRASTRUCTURE
Below is the list of fertility equipments, please choose the equipment you personally use *
X-Ray Machine
ECG Machine
Ultrasound Machines
CT Scan Machines
Medical Imaging Equipment & Accessories
MRI Machine
Mammogram Machine
Diagnostic Imaging Accessories
CBCT Machine
Gamma Camera
Fluoroscopy Equipment
Others

SERVICES

Please provide information on various procedures that you perform

Cases Taken Up Total number of services / procedures in last 1 year Min Cost Max Cost

Abdominal Ultrasound Scan Test

Yes No

CT Scan
Yes No

Chest X-Rays
Yes No

Fetal Ultrasound
Yes No
Barium Enema
Yes No

Active surveillance for prostate cancer

Yes No

Bone Density Test

Yes No

Breast MRI
Yes No

Carotid Ultrasound
Yes No

Discogram
Yes No

Heart Scan
Yes No

Lung Cancer Screening

Yes No

MRI
Yes No

Intravenous Pyelogram
Yes No

Magnetic resonance elastography

Yes No

First trimester Screening

Yes No

Mammogram
Yes No

Positron emission tomography (PET)

Yes No

Ultrasound
Yes No

Virtual Colonoscopy
Yes No

Xray
Yes No

Others
Yes No

EFFORTS
What is the average number of patients you diagnosed in a year? *

Of them, how many were related to IVF? *

Have you carried out any innovation in fertility treatment in last 1 year (2018-19)? *
Yes No

Please provide information on latest innovations that you did in last 1 year (2018-2019)

Innovation / Process Patents Average cost for each service / procedures (INR)
1
Yes No
2
Yes No
3
Yes No
4
Yes No

Best practices followed by you for ensuring higher success rate & quality treatment. *

EXPERTISE-UPDATION
Total No. In the capacity of attendee In the capacity of speaker
How many seminars and conferences were
attended by you in the year 2018-19 ?

Number of international conferences that

you participated in last 3 years

Number of national conferences that

you participated in last 3 years

Number of Research Articles written by

you published in last 3 years *