To,

Directorate of Health Services,

Madhya Pradesh.
Subject : Application (NHS2326241) for Registration of Nursing Home
 
 
 

Form - 'A'
(See rules 3 and 6)
Application for Registration/Renewal of registration under sub-section (1) of Section 4 of
Madhya Pradesh Upcharyagriha Tatha Rujopchar Sambandhi Sthapanaye ( Registrikaran Tatha Anugyapan ) Adhiniyam, 1973

PART - A - GENERAL

(1) Full Name of the applicant : SAURABH SIROTHIYA

(2) Full residential address of the applicant : BEHIND INCOMETAX OFFICE BINA ,PRATAP WARD AAGASOD ROAD
BINA STATION ,BINA Bina(Block) SAGAR 470113
(3) Technical qualifications if any, of applicant : Other
(4) Nationality of then applicant : FOREIGN NATIONAL
(5) Situation of the registered or principal office** of the Company, Society, Association or other body corporate as
Proprietor

(6) Name and other particulars of the nursing home or the clinical establishment in respect of which the registration is applied for :
APEX HOSPITAL
(7) Place where the nursing home/clinical establishment is situated : Allopathy SASTRI WARD ,BINA ,BINA Bina(Block)
SAGAR 470113
(8) Whether the applicant is interested in any other nursing home/clinical establishment or business and, if so, the place where
such nursing home/clinical establishment is situated or where such business is conducted : No

* In case application is made on behalf of a Company, Society, Association or other body corporate, the name and residential address of the person in charge of the
management of such Company, Society, Association or Body Corporate should be given.
** This item is applicable only when the application is made on behalf of a Company, Society, Association or other Body Corporate.

Page 1 Note : This is a Digitally Signed document On 11/03/2023 06:04 PM

 PART - B - NURSING HOME

(9) Brief description of construction, site and equipment of the nursing home or any premises used in connection therewith as
detailed below :
(i) Floor space of bed rooms provided for patients giving number of beds.
No. of Beds
No of
Floor in the Unit
No. of Oxygen beds Oxygen
Room Type Space/Area (without Remarks
Rooms with Medical Supply
(in sq. ft) oxygen
Gas Pipeline
support)
Isolation Unit 3000 30 0
HDU 2900 30 0
L i q u i d
Medical
Oxygen Support Unit 2000 0 30
O x y g e n
(LMO) Tank
ICU 1000 10 0
Trauma Unit 1500 20 0

(ii) Arrangement made for medical check-up :Yes , 3 MONTHS Month(s)

and for immunization of the employees : Yes

(iii) Floor space of kitchen, servants rooms and other rooms giving details of user and area of each room.

Floor Space/Area (in sq.

Room Type No. of Rooms Remarks
ft)
Other : SERVANT
110 5
ROOM

(iv) Details of arrangements made for sanitary convenience for patients and employees giving their numbers.

Sanitary Arrangement No. of Arrangements Remarks

Indian Style 8
Western Style 6

(v) Details of arrangements made for storage : Other

and service of food : No Service

(10) Whether the nursing home or any premises used in connection therewith are used or are to be used for purposes other than that
of carrying on a nursing home : No

(11) (a) Number of beds for maternity patients.

(b) Number of Beds for other patients.

No. of Beds
No of Oxygen
Floor in the Unit
beds with Oxygen
Room Type Space/Area No. of Rooms (without Remarks
Medical Gas Supply
(in sq. ft) oxygen
Pipeline
support)
Isolation Unit 3000 30 0
HDU 2900 30 0

Page 2 Note : This is a Digitally Signed document On 11/03/2023 06:04 PM

 L i q u i d
Oxygen Support M e d i c a l
2000 0 30
Unit O x y g e n
(LMO) Tank
ICU 1000 10 0
Trauma Unit 1500 20 0

(12) Names, ages and qualifications of the members of the nursing staff in the nursing home.

Staff Type Name DOB Qualification Registration No.

Nursing Staff Mr. SAURABH SIRSWA 29/08/1996 GNM Nursing 52474
Nursing Staff Ku. RASHMI DILLU 07/09/1994 GNM Nursing 35268
Nursing Staff Mr. AMARJEET SINGH 15/11/1990 GNM Nursing 35409
Nursing Staff Mr. AMIT KUMAR 01/07/1990 GNM Nursing 44637
Nursing Staff Mrs. YOGITA BHONSLE 10/08/1979 GNM Nursing 35413
Nursing Staff Mr. ANIL KUMAR 20/11/1989 GNM Nursing 41089
Nursing Staff Ku. ANURADHA 18/07/1991 GNM Nursing 43401
Nursing Staff Mr. CHANDMAL LODHIA 12/05/1990 GNM Nursing 35197
Nursing Staff Mr. DEEPAK MOR 13/09/1993 GNM Nursing 35405
Nursing Staff Mr. MOHAMMAD SALEEM 10/07/1983 GNM Nursing 35412
Nursing Staff Mr. MUKESH KUMAR NAGAR 06/07/1981 GNM Nursing 35202
Nursing Staff Mr. RAJKUMAR 05/07/1992 GNM Nursing 42005
Nursing Staff Mr. RAMESH CHAND CHAUDHARI 30/05/1985 GNM Nursing 28765
Nursing Staff Mr. SHAFEE AHMAD 25/04/1989 GNM Nursing 51165
Nursing Staff Mr. SUJEEV KUMAR 10/02/1990 GNM Nursing 35406
Nursing Staff Mr. TARUN SINGH KUNTAK 12/12/1985 GNM Nursing 35751
Nursing Staff Mr. VINOD SINGH SOLANKI 08/07/1991 GNM Nursing 45887
Nursing Staff Mr. VINOD KUMAR 02/06/1990 GNM Nursing 51059
Nursing Staff Mr. LAKSHMAN SINGH SHARMA 07/07/1986 B.Sc Nursing 3260
Nursing Staff Mr. SURESH KUMAR RAWAL 11/04/1983 B.Sc Nursing 4898
Nursing Staff Mr. BHARAT LAL YADAV 10/10/1990 B.Sc Nursing 3485
Nursing Staff Mr. PRADEEP BAJIYA 03/10/1987 B.Sc Nursing 1997
Nursing Staff Mr. GOVIND PRASAD 28/08/1988 B.Sc Nursing 0823
Nursing Staff Mr. BRAJBIHARI SHARMA 08/07/1988 B.Sc Nursing 22456
Nursing Staff Mr. DANGSAWA LARNI 05/05/1992 B.Sc Nursing 25801
Nursing Staff Mr. RUPESH KUMAR SIRSWA 04/11/1986 B.Sc Nursing 101157
Nursing Staff Mr. SARANDEEP KAUR 05/08/1998 B.Sc Nursing 33937

(13) Place where the nursing staff is accommodated : No

(14) Names, ages and qualifications of the resident or visiting physicians or surgeons in the nursing home.

(15) (a) Whether the nursing home is under the supervision of a qualified medical practitioner and if so his or her name, age and
qualifications.

(b) omitted 1

(16) (a) Whether the maternity home being maintained within the nursing home is under the supervision of a qualified nurse or a
midwife and if so, their names, age and qualifications.

Staff Type Name DOB Qualification Registration No.

Nursing Staff Mr. SAURABH SIRSWA 29/08/1996 GNM Nursing 52474
Page 3 Note : This is a Digitally Signed document On 11/03/2023 06:04 PM
Nursing Staff Ku. RASHMI DILLU 07/09/1994 GNM Nursing 35268
Nursing Staff Mr. AMARJEET SINGH 15/11/1990 GNM Nursing 35409
Nursing Staff Mr. AMIT KUMAR 01/07/1990 GNM Nursing 44637
Nursing Staff Mrs. YOGITA BHONSLE 10/08/1979 GNM Nursing 35413
Nursing Staff Mr. ANIL KUMAR 20/11/1989 GNM Nursing 41089
Nursing Staff Ku. ANURADHA 18/07/1991 GNM Nursing 43401
Nursing Staff Mr. CHANDMAL LODHIA 12/05/1990 GNM Nursing 35197
Nursing Staff Mr. DEEPAK MOR 13/09/1993 GNM Nursing 35405
Nursing Staff Mr. MOHAMMAD SALEEM 10/07/1983 GNM Nursing 35412
Nursing Staff Mr. MUKESH KUMAR NAGAR 06/07/1981 GNM Nursing 35202
Nursing Staff Mr. RAJKUMAR 05/07/1992 GNM Nursing 42005
Nursing Staff Mr. RAMESH CHAND CHAUDHARI 30/05/1985 GNM Nursing 28765
Nursing Staff Mr. SHAFEE AHMAD 25/04/1989 GNM Nursing 51165
Nursing Staff Mr. SUJEEV KUMAR 10/02/1990 GNM Nursing 35406
Nursing Staff Mr. TARUN SINGH KUNTAK 12/12/1985 GNM Nursing 35751
Nursing Staff Mr. VINOD SINGH SOLANKI 08/07/1991 GNM Nursing 45887
Nursing Staff Mr. VINOD KUMAR 02/06/1990 GNM Nursing 51059
Nursing Staff Mr. LAKSHMAN SINGH SHARMA 07/07/1986 B.Sc Nursing 3260
Nursing Staff Mr. SURESH KUMAR RAWAL 11/04/1983 B.Sc Nursing 4898
Nursing Staff Mr. BHARAT LAL YADAV 10/10/1990 B.Sc Nursing 3485
Nursing Staff Mr. PRADEEP BAJIYA 03/10/1987 B.Sc Nursing 1997
Nursing Staff Mr. GOVIND PRASAD 28/08/1988 B.Sc Nursing 0823
Nursing Staff Mr. BRAJBIHARI SHARMA 08/07/1988 B.Sc Nursing 22456
Nursing Staff Mr. DANGSAWA LARNI 05/05/1992 B.Sc Nursing 25801
Nursing Staff Mr. RUPESH KUMAR SIRSWA 04/11/1986 B.Sc Nursing 101157
Nursing Staff Mr. SARANDEEP KAUR 05/08/1998 B.Sc Nursing 33937

(b) Whether any unregistered medical practitioner or unqualified nurse, unqualified midwife is employed for nursing of patient in
the nursing home.

No

(17) Fees charged to patients.

Equipment Fees
Registration Charges 200
Other : OPD 200
Other : DUTY DOCTOR FEES 500
Nursung Charges-Pattern A-General Ward 500
Other : IPD REGISTRATION CHARGE 200
Other : CONSULTAION FEES 500
Other : SEMI PRIVATE WARD 1000
Other : PRIVATE WARD 2000
Other : SUPER DELUXE WARD 2500
Other : ICU BED CHARGE 3000
Other : CENTRAL LINE CHARGE 2000
Other : VENTILATOR CHARGE PER DAY 5000
Other : LUMBER PUNCTURE 2000
Other : TRACHEPSTOMY 5000
Other : INJECTION CHARGE 50
Other : BLOOD TRANSFUSION CHARGE 800
Page 4 Note : This is a Digitally Signed document On 11/03/2023 06:04 PM
ECG 250
Other : DR HOME VISIT CHARGE 1000
Other : MAJOR OT CHARGE 3000
Other : MINOR OT CHARGE 500

Note: The desired information under various clauses shall be attached as annexure in appropriate clause.
I solemnly declare that the above statements are true to the best of my knowledge and belief.

Date 11-Mar-2023

Thanking you,
Yours faithfully,
APEX HOSPITAL

(Authorised Signatory)

Digitally Signed By Saurabh Sirothiya (null)

Date : 11-Mar-2023 18:04:54 IST

Page 5 Note : This is a Digitally Signed document On 11/03/2023 06:04 PM