e-Hospital On-boarding Request

Request for e-Hospital^@NIC

Facility Name^*:

Facility Abbreviation(if any):

Facility Type^*:

About^*:

Central/State Govt.^*:

State^*:

District^*:

Address^*:
(max 100 characters)

Pin^*:

Website:

Average Number of (patients/day):

New OPD:

Casualty:

Follow-up OPD:

Patients Admitted:

Patients Discharged:

Other Infrastructure Details:

No. of Bed:

No. of General Ward:

No. of Private Ward:

No. of ICU:

No. of Doctor:

No. of Nurse:

No. of Clinic:

No. of Department:

Number of Counters:

OPD Registration:

Casualty Counter:

IPD Admission:

No. of Billing Counters:

Pharmacy Counters:

Laboratory Details:

No. of Laboratory:

No. of Sample Collection Centre:

Radiology Details:

No. of Radiology Equipment:

Store Details:

No. of Stores:

No. of Sub-stores:

Blood Bank Available:

Any other relevant information:

Availability of Local Area Network (LAN):

No. of Nodes:

Desktop PCs:

Number:

Configuration:

No. of Printers:

Availability of Internet Connectivity:

Bandwidth (MBPS):

Availability of Redundant Connectivity (different ISP):

Bandwidth (MBPS):

Technical Manpower Details:

No. of Technical Manpower resources:

Details of Technical Manpower resources:

Availability of UPS:

Capacity (KVA):

Availability of Generator :

Capacity (KVA):

Previous HMIS Application:

Any HMIS application already implemented:

Name of the organization and details of modules implemented:

Date of implementation of the HMIS application:

Platform of the HMIS application:

Initials ^*:

First Name^*:

Middle Name:

Last Name^*:

Designation^*:

Phone Number:

Mobile Number^*:

Email^*:

Fax:

Initials ^*:

First Name^*:

Middle Name:

Last Name^*:

Designation^*:

Phone Number:

Mobile Number^*:

Email^*:

Fax:

I agree to the terms & conditions

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Request for e-Hospital@NIC

Request for e-Hospital^@NIC