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Membership Application Form
Operated by VAULT (SL) Limited
HEALTH CONNECT MEMBERSHIP APPLICATION
1. APPLICANT INFORMATION
Clinic Name:
Clinic Registration No. Clinic Code: Clinic Phone:
Clinic Current address:
City: Area or Region: Clinic Email:
Clinic Registered Type (Please circle) Clinic Status Clinic Primary Contact (Please indicate Below)
Clinic Lab
Co-Ordination Clinic
Private Government NGO
Please Indicate if Clinic is registered with
any regulatory or Governing instiution (eg. Medical Council etc)
2. CLINIC OWNER INFORMATION
Name of Owner:
Clinic Owner address: Area or Region
Clinic Owner Phone: Clinic Owner E-mail: Postal Address
City: Nationality: License or Registered Code:
Are you medical personnel? If yes please indicate
3. OPERATIONAL INFORMATION
Operational Hours opened to the Public
Day Time
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday
Do you have a regular Electricity Supply? Yes or No. If Not indicate alternative
Do you have a computer device? Yes or No if Yes Please Tick Device ( PC, Laptop, Tablet or Smart
Mobile)
Are the devices in proper working order? Yes or No
HEALTH CONNECT MEMBERSHIP APPLICATION
4. OPERATIONAL INFORMATION - SERVICES
Please indicate the type (s) of services you are offering to the public: Consultation Ultrasonography X-Ray Pathology Bone Densitometry CT SCAN MRI
Mammography
Please tick the applicable services your institution is offering
ULTRASONAGRAPHY
o USG - UPPER ABDOMEN o SONOMAMMO 1 BREAST
o USG TRANS RECTAL o USG CRANIAL
o USG CHEST o USG-OVULATION EXTRA SITTING
o USG NECK 2 o FETAL ECHO
o USG - ABDOMEN & PELVIS
o COLOUR DOPPLER - BOTH UPPER LIMBS
ARTERIES o VENOUS COLOUR DOPPLER STUDY FOR LOWER
LIMB o COLOUR DOPPLER OF UPPER LIMB
o COLOUR DOPPLER - PENILE o DOPPLER STUDY OF PAROTID GLAND
o VENOUS COLOUR DOPPLER STUDY FOR BOTH LOWER LIMBS o SONOGRAPHY (FWB)
o COLOUR DOPPLER - CAROTID STUDY o SUPERFICIAL SWELLING-SONO o COLOUR DOPPLER OF FOETALPLACENTAL
CIRCULATION o USG GUIDED ASPIRATION
o COLOUR DOPPLER OF ARTERIAL o ABDOMEN WITH FOETUS
o USG PELVIS o SONO-MAMMOGRAPHY
o USG THYROID o SONO-ABD WITH TVS
o USG FOLLICULAR STUDY o USG GUIDED DIAGNOSTIC TAP / FNAC
o USG TRANS VAGINAL SONOGRAPHY o USG GUIDED DRAINAGE / PROCEDURE
o USG SCROTUM o USG GUIDED PROCEDURE
o COLOUR DOPPLER OF BOTH LOWER LIMB
ARTERIAL SYSTEM o USG GUIDED TH. ASPIRATION
o USG ORBIT o LOWER LIMB VASCULAR DOPPLER
o TWINS ANOMALY SCAN o USG ABDOMEN AND SCROTUM
o TWINS DOPPLER o USG-PERIANAL
o TWINS PREGNANCY o USG-FWB FOR NT
o DOPPLER LOWER LIMB ART & VEN (BOTH LIMBS)
o USG DOPPLER RENAL
o USG SHOULDER
Any other please Specify
HEALTH CONNECT MEMBERSHIP APPLICATION
X-RAY
o MASTOID (BOTH LATERAL) XRAY o ABDOMEN STANDING
o X-RAY MANDIBLE o X-RAY BOTH ANKLE - AP & LAT
o X-RAY DORSAL SPINE - LATERAL
o ANKLE AP/LAT o X-RAY BOTH HAND WITH WRIST - AP & LAT
o X-RAY DORSAL SPINE AP o X-RAY BARIUM ENEMA
o X-RAY SACRO COCCYX SPINE - AP & LAT o STYLOID VIEW
o X-RAY CERVICAL SPINE - LAT o T M JOINT X-RAY
o X-RAY CERVICAL SPINE - AP o X-RAY BOTH FOOT - AP & LAT
o X-RAY SHOULDER AP o BOTH HAND AP
o X-RAY L S SPINE - LAT o X-RAY BOTH KNEE STANDING -AP
o X-RAY SKULL - AP & LAT o BOTH TM JOINTS (OPEN & CLOSED MOUTH)
o X-RAY KUB o X-RAY CALCANEUM AXIAL/LAT
o X-RAY COCCYX - LATERAL o
o X-RAY COCCYX - AP o CHEST (PA & LAT)
o X-RAY DORSAL LUMBAR SPINE o X-RAY CHEST - LORDOTIC
o X-RAY SHOULDER AP/LAT o COLOGRAM
o X-RAY KNEE JOINT o X-RAY DORSAL SPINE - AP & LAT
o X-RAY HSG (HYSTEROSALPINGOGRAPHY) o ELBOW (AP / LAT)
o ROUTINE X-RAY o ELBOW AP/LAT (BOTH) X-RAY
o X-RAY MCU (MICTURITING CYSTO-URETHROGRAM) o X-RAY FISTULOGRAM
o X-RAY BARIUM MEAL FOLLOW THROUGH
(SMALL BOWEL) o HIP JOINT AP
o X-RAY BARIUM MEAL STOMACH DUODENUM o HIP JOINT AP / LAT
o X-RAY BOTH HEELS (LATERAL) o X-RAY L S SPINE - AP
o X-RAY NASOPHARYNX LATERAL VIEW FOR ADENOIDS o L S SPINE AP-LAT
o X-RAY CLAVICLE (AP) o NASAL BONE BOTH LAT
o X-RAY FOOT (AP/LATERAL) o X-RAY NECK LAT
o X-RAY FINGER (AP/LATERAL) o PELVIMETRY
o X-RAY HAND (AP/ LATERAL) o PNS (WATERS)
o X-RAY FEMUR (AP / LATERAL) o SCAPHOID AP/LAT/OBLIQUES
o X-RAY SKULL - LAT o X-RAY SINOGRAM
o X-RAY SKULL - AP o WRIST AP/LAT
o X-RAY CHEST LATERAL o X-RAY BOTH HEELS AP & LAT
o X-RAY CHEST - PA o BOTH SHOULDER AP -XRAY
o X-RAY ABDOMEN - SUPINE AP o HAND AP X-RAY
o X-RAY HEELS (AXI/LATERAL) o MANDIBLE AP X-RAY
o X-RAY HIP JOINT LATERAL o MAXILLA AP & LAT X-RAY
o X-RAY FOREARM (AP/LATERAL) o X-RAY ORBITS - AP & LAT
o X-RAY CERVICAL SPINE- AP & LAT o STYLOID VIEW
o X-RAY BOTH PATELLA – SKYLINE
o T M JOINT X-RAY
o X-RAY BOTH HAND WITH WRIST - AP & LAT
X-RAY ORBITS - AP
HEALTH CONNECT MEMBERSHIP APPLICATION
o X-RAY ORBITS - AP
o X-RAY PELVIS - AP & LAT
o THIGH AP/LAT X-RAY
o BOTH KNEE JOINT A.P/LATERAL-XRAY
o X-RAY BOTH S.I.JOINTS
o X-RAY CALCANEUM-LATERAL
o X-RAY DORSO LUMBAR SPINE - AP & LAT
o X-RAY DORSOLUMBAR SPINE - LATERAL
o X-RAY LEG A.P./LATERAL
o RIBS AP
o X-RAY CHOLANGIOGRAM
o PELVIS X-RAY AP VIEW
o MAXILLA PA VIEW
o XR KNEE-SKYLINE VIEW
o X-RAY
o OPG
Any other Please Specify
HEALTH CONNECT MEMBERSHIP APPLICATION
PATHOLOGY
o 24 HRS URINE ANALYSIS o CARDIAC INJURY PROFILE
o 24 HRS URINE MICROALBUMINURIA o CARDIAC PROFILE
o A/G RATIO o CBC WITH INDICES (HAEMOGRAM)
o ABSOLUTE EOSINOPHIL COUNT o CHLORIDE
o ABSOLUTE NEUTROPHIL COUNT o CHOL: HDL CHOL RATIO
o ADENOSINE DEAMINASE (ADA) o CLOT RETRACTION TIME (CRT) o AFB SMEAR o AFB SMEAR PUS o ALBUMIN SERUM o COAGULATION PROFILE
o ALKALINE PHOSPHATASE
o AMMONIA
o AMPHETAMINE (URINE) (DRUG OF ABUSE)
o AMYLASE, SERUM
o ANTE-NATAL PROFILE
o APTT
o ARTERIAL BLOOD GASES
o ASO TITER
o ASPIRATION OF ASCITIC / PLEURAL FLUID
o BENCE JONES, URINE
o BETA-2 MICROGLOBULIN (SERUM)
o BILIRUBIN
o BLEEDING TIME & CLOTTING TIME
o BLOOD CULTURE
o BLOOD GLUCOSE (F&PP)
o BLOOD GLUCOSE FASTING
o BLOOD GLUCOSE PG (75 GMS OF GLUCOSE)
o BLOOD GLUCOSE POST PRANDIAL
o BLOOD GLUCOSE RANDOM
o BLOOD GROUP & RH (D) FACTOR
o BLOOD UREA
o BLOOD UREA NITROGEN
o BONE MARROW STUDY
o CALCIUM
o CALCIUM, IONIZED o COMPLETE BLOOD COUNT o
o GAMMA GLUTAMYL TRANSFERASE (GGT)
o GLOBULIN
o GLUCOSE TOLERANCE TEST
o o
o o
o o
o o
HEALTH CONNECT MEMBERSHIP APPLICATION
PATHALOGY CONTD
o CREATINE KINASE - MB (CK-MB), SERUM o HCV TOTAL
o CREATINE KINASE (CPK), SERUM o HDL CHOLESTEROL
o CREATININE o HISTOPATHOLOGY - SMALL
o CSF EXAMINATION o HISTOPATHOLOGY- LARGE
o DENGUE (QUALITATIVE) o HISTOPATHOLOGY- MEDIUM
o DENGUE ANTIGEN (NS 1) o HIV
o DIABETES CHECK UP o HYPERTENSION PROFILE/CARDIAC PROFILE
o DIABETES PROFILE (MAXI) o LDH FLUID
o DIABETIC PROFILE o LDL CHOLESTEROL
o DIFFERENTIAL COUNT o LDL CHOLESTEROL (DIRECT)
o E.S.R. o LDL:HDL RATIO
o FEVER PROFILE (MAXI) o LIPID PROFILE
o FEVER PROFILE (MINI) o LIVER FUNCTION TEST (HEPATIC PROFILE) o FINE NEEDLE ASPIRATION CYTOLOGY TEST
(FNAC) o MANTOUX TEST
o FLUID PROTEIN o MP(QBC)
o FNAC PROCEDURE o OBESITY PROFILE
o FUNGAL SMEAR - KOH o OCCULT BLOOD (STOOL)
o G6PD (QUALITATIVE) o PACER 26
o GAMMA GLUTAMYL TRANSFERASE (GGT) o PAP SMEAR
o GLOBULIN o PARTIAL THROMBOPLASTIN TIME
o GLUCOSE TOLERANCE TEST o PCV
o GLUCOSE TOLERANCE TEST (GTT-2) o PERIPHERAL BLOOD SMEAR (HB/TLC/DC)
o GLYCOSYLATED HB (HBA1C) o PHOSPHORUS o GTT - F, 1, 2, 3 HRS (100 GMS GLUCOSE -
PREGNANCY) o PLATELET COUNT, EDTA WHOLE BLOOD
o GTT (100 GMS GLUCOSE) o PLEURAL FLUID - ADA
o GTT (50 GMS GLUCOSE) o PLEURAL FLUID - PROTEIN
o GUIDED FNAC o POTASSIUM
o HAEMOGLOBIN o PREGNANCY TEST o HB D.C.T.L.C o HBSAG o PRE-OPERATIVE PROFILE
o PUS CULTURE o PROTEINS
o RAPID MALARIA TEST FOR PLASMODIUM LDH o PROTEIN-SPOT/24 HRS. URINE
o RENAL PROFILE o PROTHROMBIN TIME
o RETICULOCYTE COUNT o PT INR (INR RATIO)
o RHEUMATOID FACTOR
o SEMEN ANALYSIS
o SEMEN CULTURE
o SEMEN FRUCTOSE, SEMEN
o SERUM ELECTROLYTES
HEALTH CONNECT MEMBERSHIP APPLICATION
PATHALOGY CONTD
o SGOT (AST)
o SGPT (ALT) o URINE COTININE
o SMA - 12 o URINE CULTURE
o SMA - 12 + 2 o URINE FOR BILE PIGMENT
o SODIUM o URINE FOR BILE PIGMENTS & SALTS
o SPUTUM FOR CULTURE o URINE FOR BILE SALT
o SPUTUM GRAM STAIN o URINE KETONE
o SPUTUM ROUTINE (GRAM STAIN+Z N STAIN) o URINE ROUTINE
o STONE ANALYSIS (CALCULI) o URINE UROBILINOGEN
o STOOL ANALYSIS o VDRL, SERUM
o STOOL FOR CULTURE o VLDL CHOLESTEROL
o STOOL FOR OCCULT BLOOD o WIDAL TEST – TUBE METHOD
o STOOL ROUTINE o WIDAL TEST, SERUM
o STOOL ROUTINE & PH o ZN STAINING
o SWAB CULTURE
o TLC/DLC (5 PART)
o TOTAL BODY PROFILE
o TOTAL CHOLESTEROL
o TOTAL LEUCOCYTE COUNT (TLC)
o TRIGLYCERIDE
o TROPONIN T,
o TYPHI DOT (IGG & IGM)
o URIC ACID Any other Please Specify CONSULTATION
o Family Physician Consultation
o Family Physician Consultation Follow Up
o Pediatric Consultation
o Pediatric Consultation Follow Up
o Dental Consultation
o Dental Consultation Follow Up
o Neurology Consultation
o Neurology Consultation Follow Up
o Cardiology Consultation
o Cardiology Consultation Follow up
o Chest Physician Consultation
o Chest Physician Consultation Follow up
o Ophthalmology Consultation
o Ophthalmology Consultation Follow Up o Orthopedic Consultation
HEALTH CONNECT MEMBERSHIP APPLICATION
CONSULTATION CONTINUES
o Orthopedic Consultation Follow Up
o Physiotherapy Consultation
o Physiotherapy Consultation Follow Up
o Urology Consultation
o Urology Consultation Follow Up
o Gastroenterology Consultation
o Gastroenterology Consultation Follow Up
o Diet Consultation
o Diet Consultation Follow Up
o ENT Consultation
o ENT Follow Up
o ENT Syringing
o Gynaecology Consultation
o Gynaecology Consultation Follow Up
o General Physician Consultation
o General Physician Consultation Follow Up
o Dermatology Consultation
o Dermatology Consultation Follow Up
o Surgical Consultation
Any other please Specify
HEALTH CONNECT MEMBERSHIP APPLICATION
CT SCAN
o 3DCT
o Abdomen & Pelvis o CT Venogram
o Abdomen (Do Not Use) o Dental - Mandible
o Anesthesia Charges (CRH) o Dental - Mandible and Maxilla
o Anesthesia Charges (JRH) o Dental - Maxilla
o Anesthesia Charges (PNH) o Emergency Charges
o Angio Limb Vessels o Extremity Both Hips
o Angio Lower Limb o Extremity.
o Aorta Angio o Full Abdomen (Do Not Use)
o Biopsy Gun Charges o Guided Aspiration - Dr. Devang Desai
o Both Ankles o Guided Core Biopsy - Dr. Bhavin Jankharia
o Both Extrimity o Guided Core Biopsy - Dr. Devang Desai
o Brain o Guided Core Biopsy - TATA - Dr. Bhavin Jankharia
o Brain - Limited o Guided Core Biopsy - TATA - Dr. Devang Desai
o Bronchoscopy o Guided Core Biopsy (JRH)
o Cardiac o Guided Core Biopsy
o Cardiac and Pediatric o Guided FNAC
o Cardiac Calcium Scoring o Guided Lumbar Sympathectomy
o Catheter Drainages o Guided Pig and Tail
o Cerebral Angio o Head & Neck
o Chest o Head & Orbit (Do Not Use)
o Cisternography o Head (Do Not Use)
o Colonoscopy, Virtual Endoscapy o Limited Scan For Biopsy
o CT Angio o Lungs - HRCT
o CT Arthrogram o Myelography
o CT Enteroclysis o Neck (Do Not Use)
o CT Extremity - Shoulder - Bone Loss o Non Ionic Contrast (Do Not Use)
o CT Face o Obesity Trial - SBM/14/07 Protocol
o CT Future Liver Remnant o Orbits
o CT Guided Aspiration o Pelvis - for Bones
o CT Guided Block - Epidural o Pelvis - for Soft Tissue
o CT Guided Block - Facet Joint
o CT Guided Block - Foraminal o Peripheral Angio
o CT Guided Lumbar Sympathectomy o Pigtaill Catheter
o CT Guided Nerve Block o PNS - HRCT
o CT Kub o R F Ablation
o CT Pelvimetry (Do Not Use) o RT Planning (Do Not Use)
o CT Pulmonary Angio o S I Joints (Do Not Use)
o CT Scanogram o Spine
o CT Urography - IVU o Spine - Cervical
o Spine - Dorsal
o Spine - Lumbar
HEALTH CONNECT MEMBERSHIP APPLICATION
CT SCAN CONTD
o Temporal Bone
o Thorax
o TM Jt
o Upper Abdomen
o Virtual Brochoscopy
o Virtual Colonscopy
o Cardiac PET/CT
o Brain PET CT Scan
o Whole Body PET CT
Any other please specify
BONE DENSITOMETRY
o DXA
o DXA - Hip
o DXA - Hip & L Spine
o DXA - L Spine
o Whole Body DXA
MAMMOGRAPHY
o Digital Mammography
o Mammo Guided Hook-wire loc
o MAMMOGRAPHY
o MAMMOGRAPHY - DUCTOGRAM
o Mammography - Unilateral
o Second Opinion
Any other specify
HEALTH CONNECT MEMBERSHIP APPLICATION
MRI
o Abdomen o MR Fistulogram
o Anesthesia Charges o MR Myelography
o Ankle o MR Urography
o Arm o MR Veno
o Both Foot o MR Venography both upper limb - both lower limb
o Both Knee o MRCP
o Both Leg o MRI - MARS Protocol
o Both Shoulders o MRI - MARS Protocol.
o Both Wrist o MRI MARS B-L J & J
o Brachial Plexus or Thorax Inlet o MRI Pelvis - HIFU Screening
o Brain - Epilepsy Protocol o MRI Tractograms
o Brain - MS Protocol o MRI Whole Body Stir
o Brain - Screening o Myositis Protocol
o Brain - Spectroscopy o Neck
o Breast o Obstetric MRI
o C - Spine Dynamic MRI o Orbit
o Cardiac - Coronaries o Pelvis
o Cardiac - Stress Perfusion o Renal Angio
o Cardiac - Stress Perfusion Exercise Induced o S I Joints o Cardiac and Thalassemia and Iron Loading
Assessment o S I Joints Limited
o Cardiac - Viability Imaging o Screening
o Carotid Plague Morphology o Screening Whole Spine
o Contrast Only o Screening.
o Elbow o Shoulder
o Femur o Spine - Cervico-Dorsal
o Ferri Scan o Spine - CVJ
o Fetal MRI o Spine - Dorso-Lumbar
o Foot o Spine - MS Protocol
o Forearm o Spine - Screening
o Functional MR o Thigh
o Hand o Thumb
o Head o Tumor Protocol
o Hip o Tumor Protocol with DTI
o Knee o Wrist
o Knee Patella Tracking - MRI
o L - Spine Stress MRI
o Leg
o MR Angio
o MR Arthrogram
o MR Body Angio
o MR Enteroclysis
o MR Extended Study o MR Finger
AAAAAAAA
HEALTH CONNECT MEMBERSHIP APPLICATION
CLINIC PERSONEL INFORMATION – MEDICAL OFFICERS
Please add personnel in the spaces below
Name Designation/Functions Email/Contact Number
1.
2.
3.
4.
5.
6.
CLINIC PERSONEL INFORMATION – NON MEDICAL OFFICERS
Please add personnel in the spaces below
Name Designation/Function Email/Contac Number
CLINIC FACILITY INFORMATION
Do you have an admission facility? Yes or No if Yes Please Indicate below
Unit/Section No. of Beds Remarks
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