tygyut

Registration Form for ART Clinic

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

Gynaecologist Name:

Gynaecologist Qualification:

Gynaecologist Registration No. (if applicable):

Anaesthetist Name:

Anaesthetist Qualification:

Anaesthetist Registration No. (if applicable):

Clinical Embryologist Name:

Clinical Embryologist Qualification:

Clinical Embryologist 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:

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

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.