7/30/2021 Department of Health and Family Welfare

Department of Medical Health and Family Welfare

Government of Uttar Pradesh

Online Application Form for Registration of Medical Establishment

To, Application Number : MEE0010474

The Chief Medical Office,
Distt : Prayagraj
Uttar Pradesh
Sir,
Kindly Register my Clinic/medical establishment details of which are given as below

1 Details of Establishment :

Establishment Area Urban Place of Establishment Own

Type Of Land Commercial Establishment Name Pushpanjali Pathology

Center

Category Pathology labs Operated By Individual Person

Name of Individual Person Yuvraj Singh Building Structural Layout

2 Address of Medical Establishment :

Telephone / Mobile No. NA Website NA

Address Kalindipuram Chauraha District Prayagraj

Rajrooppur Prayagraj

State Uttar Pradesh Pincode 211011

Address Proof

3 Medical facilities:

Details of Medical facilities Pathology Labs

offered

4 Details of Owner :

Name Yuvraj Singh Age 28

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Father Name Sri Mahesh Singh Mobile Number 9838965986

E-mail Id edsingh2@gmail.com Address Kalindipuram Chauraha

Rajrooppur Prayagraj

State Uttar Pradesh District Prayagraj

Pin Code 211011 Photo

Signature Owner & Person in charge No

are same?

5 Details of Person Incharge :

Name Dr Akhilesh Kumar Mobile Number 9838965986

E-mail edsingh2@gmail.com Relevant Qualification MBBS

Institution Name GSVM Medical College Registration No(MCI/SMF). 19671

Kanpur

Name of Central/ State UP State Medical Council Address 815 Bharat Clinic
Council Rajrooppur Prayagraj

State Uttar Pradesh District Prayagraj

Pincode 211011 Photo

MCI/SMF Certificate

6 Doctor's Details :

Doctor Father Relevant Registration Registration Part/Full

Sl.No. Name Name Qualification Foundation Type No. Time Attachme

1 DR SRI MBBS GSVM MCI 19671 Part 

AKHILESH BHARAT MEDICAL Time
KUMAR PRASAD COLLEGE
KANPUR

7 Paramedical Staff Details :

Note:- Please fill details and upload records up to 5 ParaMedical Staff through Add more option &
Furnish details of rest ParaMedical
Staff in affidavit in same format as mentioned below. Submit
hardcopy of all the remaining records (qualification document) of ParaMedical Staff to the CMO
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Office/ Committee.
Father Relevant Registration Registration Part/Full
Sl.No. Name Name Qualification Institution Type No. Time Attachm

1 YUVRAJ SRI DMLT GOVERNMENT SMF LT 8466 FULL 

SINGH MAHESH MEDICAL TIME
SINGH COLLEGE
JALAUN

8 Type Of Facility Offered :

InPatient No

OutPatient No

Laboratory Yes Other Laboratory NaN

Laboratory Type Pathology

,
Biochemistry

Imaging No

NOC from Pollution control Yes Certificate Number GO1451

Board

NOC from Pollution control

Board Certificate

Certificate from agency to Yes Certificate Number P2604PH

Disposal of Medical Waste

Certificate from agency to

Disposal of Medical Waste

Firefighting System in the No

Establishment

9 Attachment :

Address Proof

Upload MCI/SMF Certificate

Attach Qualification Document

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Notarized Affidavit from Person Incharge of Establisment

     
Date Place Signature of Person Incharge

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