SUBHAG
Name of the ART Clinic:
Address of the ART Clinic:
City:
State:
Pin Code:
Tel. No (with STD Code):
Mobile No. (ART Clinic):
E-mail:
Website (if any):
Status of Your ART Clinic: Government Private
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
Does your ART Clinic have a Director? Yes No
Director’s Name (if applicable):
Director’s Qualification:
Director’s Registration No. (if applicable):
Details of Staff (Position, Name, Qualification, Registration No.):
List of Equipment:
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 Pre-implantation Genetic Testing
Do you have facilities for cryopreservation of sperm/oocyte/embryo? Yes No
Cryopreservation Facilities Available: Freezing of sperm Freezing of oocytes Freezing of zygotes Freezing of embryos Cryopreservation of ovarian tissue Freezing of Testicular tissue
Any Additional Information:
I hereby declare that the entries in this form are true to the best of my knowledge and belief.
