Application for Starting Fertility Clinic

1. What's Your Name? *

2. Enter your Email? *

3. Enter Mobile Number? *

4. Hospital/Clinic Name *

5. Location or City *

6. Who are you? * Obstetrics and Gynecology (OB-GYN) Hospital Maternity Hospital Multi-Specialty Hospital Ayurvedic Hospital Nursing Home Fertility/IVF Hospital OPD Clinic

7. Hospital/clinic operated by? * Private Owner Trust Govt

8. How would you like to get contacted? * Phone call Whatsapp Email

9. Does the hospital/clinic have a gynecologist? * Yes No

10. Total area of the clinic (in square feet) * Less than 1000 Sq Ft More than 2000 Sq Ft More than 5000 Sq Ft More than 10,000 Sq Ft

11. Number of consultation rooms? *

12. Number of procedure rooms? *

13. We wish to have a Zoom Meeting, do you use calendars? * Yes No

14. Is the clinic located in a residential, commercial, or mixed-use area? * Residential Commercial Mixed-use

15. Is the clinic licensed to perform IUI procedures? (ART Level 1 Registration) * Yes No

16. Are you in position to pay Govt Fees (INR 50000) for IUI Clinic (ART Level 1) Registration? * Yes No

17. Average monthly footfall of the clinic (number of patients) *

18. Average number of infertility patients currently visiting per month *

19. Total number of infertility procedures performed per month *

20. Do you anticipate at least 10 new infertile couples visiting the clinic monthly for IUI procedures? * Yes No

21. Number of gynecologists available *

22. Number of trained nurses or assistants for IUI procedures *

23. What is the total cost of an IUI cycle at your clinic, inclusive of doctor consultation? *

24. Has the clinic been profitable in the last three years? * Yes No

25. SUBHAG HEALTHTECH will provide ART registration support, marketing assistance, and equipment supply—do you need any other help? *

26. Are all gynecologists performing IUI procedures certified? (We don't Provide Gynecologists) * Yes No

27. Have you previously engaged in any profit-sharing partnerships? * Yes No

28. If yes, briefly describe the nature and success of those partnerships *

29. Are you willing to make any necessary investments or improvements to the clinic for this partnership? * Yes No

30. Please provide any additional information or comments that you think might be relevant to this application *