MEMBERSHIP FORM

Before filling in the form please read instructions on the website. Complete the form with all the requisite Fields.

 

* This form is for direct Membership where is no branch of UPNHA is exist.

* Kindly send a Demand Draft of Rs. 400/- (Four Hundred Only ) in favor of UPNHA - LUCKNOW for membership and Nursing home bulletin.

 
* Fields are Required for Registration.

*1. Demand Draft Details  
                                                *DD No.:
                                                   *Date:   In ( DD/MM/YYYY ) Format
                       *Demand Draft Amount:   Rs.
                                         *Bank Name:
*2. Fill Information
                            *Name Of The Nursing Home:  
                                              *Address:
                                                     *City:
                                                  *State:
                                              *Country:
                                             *Pin code:
                                                   *Email:
                                   *Telephone No.: (with STD/ISD code)
                                     Mobile No. ( If any ): ( with STD/ISD code)
                            Owner of The Nursing Home / Hospital:
3. Hospital / Nursing Home Details :  Mandatory
                                      Constructed Area:
                                        No of Beds:
                                    Facilities for the emergency care:
                  Staff for round the clock care:
                                          Qualified doctor for care:
                                                Routine pathology facility:
                                          Operation theater / MOT:
4. Hospital / Nursing Home Details : Optional
                                      X-Ray / USG / MRI :   (Yes/No)
                                        Ambulence:   (Yes/No)
                                    Boyle.s Apparatus:   (Yes/No)
                  Any Other Facilities:
   
   
*DECLARATION  BY THE MEMBER

I  hereby declare that I have read and  understood the terms and conditions of the UPNHA. I fulfill the minimum eligibility criteria and I have  provided necessary information in this regard. In the event of any information found incorrectly or misleading , my membership shall be liable to cancellation by the UPNHA at any time and I shall not be entitled to refund of any amount paid by me to the UPNHA.

Check if Accept the Term & Condition of the UPNHA