ART Clinic Registration Form

Clinic Information

Name of the ART Clinic *

Address of the ART Clinic *

City *

State *

Pin Code *

Tel. No (STD Code & Country Code Start with 091) *

Mobile No. With Country Code 091*

E-mail *

Website (if any)

Status of your ART Clinic *

Date of Establishment *

Is your ART clinic registered under the following Acts? *

Medical Termination of Pregnancy (MTP) Act Pre-Conception and Pre-Natal Diagnostic Techniques (PCPNDT) Act

Director Information

Does your ART Clinic have a Director? *

Yes No

Details of Staff

Staff Member 1

Position *

Name *

Qualification *

Registration No. (if applicable)

Medical Staff

Gynaecologist Name *

Gynaecologist Qualification *

Gynaecologist Registration No. (if applicable)

Andrologist Name *

Andrologist Qualification *

Andrologist Registration No. (if applicable)

Counsellor Name *

Counsellor Qualification *

Counsellor Registration No. (if applicable)

List of Equipment Available *

Refrigerator Sperm Washing Centrifuge Microscope

ART Procedures Routinely Carried Out (Select those that apply)

Intra-uterine Insemination using Husband Semen (IUI-H) Intra-uterine Insemination using Donor Semen (IUI-D) In vitro Fertilization-Embryo Transfer (IVF-ET) Intra-cytoplasmic Sperm Injection (ICSI) Altruistic Surrogacy Processing of semen or storage of gametes (sperm & oocyte) Pre-implantation Genetic Testing Any other procedure (Specify)

Do you have facilities for cryopreservation of sperm/oocyte/embryo? *

Yes No

Any Additional Information

Legal Authorization Notice *

By submitting this form, I, the undersigned, hereby authorize Subhag HealthTech Pvt. Ltd. to act on behalf of my clinic for the purpose of completing the ART (Assisted Reproductive Technology) Level 1 Clinic Registration process. I understand and agree that Subhag HealthTech will collect, manage, and submit the necessary documentation required for the registration and will liaise with relevant authorities as needed.

I acknowledge that Subhag HealthTech Pvt. Ltd. does not guarantee the approval of the ART Level 1 registration. The final decision rests with the relevant government authorities. Furthermore, I understand that all government fees associated with this registration process will be borne by my clinic/hospital and are not covered by Subhag HealthTech Pvt. Ltd.

I also acknowledge that I have provided all information voluntarily, and I confirm that the details submitted are accurate and truthful to the best of my knowledge. I further understand that Subhag HealthTech is authorized to act solely for the purpose of this registration and that this authorization does not extend to any other legal or operational matters without my express written consent.

By proceeding with this form, I agree to these terms and authorize Subhag HealthTech Pvt. Ltd. to act as my legal representative in this regard.

I agree to the terms and authorize Subhag HealthTech Pvt. Ltd.