1. Please state the owner(s) names and details of their experience and qualifications.
2.4. Gross Revenue - Hospital/Clinic:
2.5. Gross Revenue - Rentals/Leases:
2.6. Gross Revenue - Medical Procedures/Treatments:
2.7. Gross Revenue - Pharmacies:
2.8. Gross Revenue - Any Other Source:
7. Please state number of beds maintained.
8. Number of babies delivered on an annual basis.
12. Please state number of employees in each of the following classifications.
12.2. Cardiac/Thoracis/Vascular Surgery
12.3. Dental Surgery/Maxilla-Facial
12.7. General Practitioner
12.8. General Surgery
12.10. Internal Medicine
12.11. Lab/Pathology Technicians
12.14. Nurses - Sports Scientist
12.15. Nurses - Enrolled Nurses
12.16. Nurses - Matrons
12.17. Nurses - Midwives
12.18. Nurses - Nurse Anaesthetist
12.19. Nurses - Registered Nurses
12.20. Nurses - Student Nurse
12.21. Nurses - Auxiliaries Nurses (Qualified)
12.22. Care Workers
12.28. Plastic Surgery
12.30. Residential Medical Officers
13. Please state the approximate division of your patients between:
17. Please state number of X-Ray machines/M.R.I./C.A.T. or similar scanners owned or operated, and whether they are used for:
26. Clinical Trials
35. Are the following regularly checked, serviced and repaired by fully qualified contractors?
38. Are there facilities for safe collection, storage and disposed of (in accordance with current guidelines/legislation).
39. Do you ensure that the following are safely disposed of (in accordance with current guidelines/legislation).
If yes, please provide details of this cover in chronological order in the section below.
I/We the undersigned duly authorised person(s) declare that:
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