| LifeSpring Hospital___________________________ |
A. Consultant Empanelment-Application Form |
1. Consultant Type- |
| Anesthetist |
Pediatrician |
Gynecologist |
GeneralSurgeon |
Physician |
Others (Specify) |
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2. Personal and Professional details- |
| NAME |
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| ADDRESS |
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| CONTACT NO. |
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| E-Mail ID |
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Pan Nos |
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| QUALIFICATION DETAILS |
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College |
University |
Year of passing & registration No |
| MBBS |
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| Post Graduation 1 |
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| Post Graduation 2 |
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(Enclose photocopy of certificates) |
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3. Hospital Affiliations (Kindly provide the list of hospitals/clinics with whom you are associated) |
| Name of the Institution |
Association type |
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Date-_______________ Place-_______________ Signature of the Consultant-____________________ |
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| LifeSpring Hospital_________________ |
B. Consultant Empanelment- Term Sheet |
1. Consultant Empanelment- Term Sheet |
| Sl. |
Procedure |
Charges in Rs.(All inclusive) |
| General ward |
Semi Private |
Private |
| 1 |
 30minutes |
Simple |
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| 2 |
1 hours |
Minor |
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| 3 |
2 hours |
Moderate |
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| 4 |
3 hours |
Major |
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| 5 |
4 hours |
Special |
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| Note- Please include TDS in your charges; Please see overleaf- for the terms and conditions; List of surgeries Package and non package. |
1.2 Inpatient-Observation |
| 1 |
Visit/Day (Normal) |
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| 2 |
Visit/day (Emergency) |
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| Note- Please include TDS in your charges; Please see overleaf- for the terms and conditions; List of surgeries Package and non package. |
| 1.3 Inpatient-Observation |
| Sl. |
Particulars |
Total Fee |
Consultant Share |
LifeSpring Share |
| 1 |
General |
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| 2 |
Emergency |
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| Note- Please include TDS in your charges; Please see overleaf- for the terms and conditions; List of surgeries Package and non package. |
| 1.4 For Pediatrician Only* |
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| 1.5 For Anesthetist Only* |
| Major Surgery : |
Minor Surgery : |
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| For 1.4 and 1.5 please refer to the scope of work printed overleaf in terms and condition |
2. Days and Timings |
Monday |
Tuesday |
Wednesday |
Thursday |
Friday |
Saturday |
Sunday |
Emergency |
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| 3. Declaration- |
I hereby declare that all information provided by me are true to the best of my knowledge, and in sound mind I have gone through the terms and condition printed overleaf and would abide by the same.
I would herby like to offer my services to LifeSpring Hospital-____________________
Date-_______________ Place-_______________ Signature of the Consultant-____________________
Date-_______________ Place-_______________ Signature of the Administrator-__________________
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4.Validity ___________months/year from the date of signature of the term sheet.
c.c. Empanelled Consultant; Administrator (LifeSpring___________) ; Finance CFO; HR CFO.
* Refer to terms and condition printed overleaf
Dear consultants please attach your suggestion with the term sheet; we would like to continually improve.
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