Facility Rental Request

Personal Details

Name:
Designation:
Institute Affiliated with:
Phone (mobile):
Phone (office):
Email:
Contact details:

Session Details

Session/Topic Title :

Large Group talk: NoYes
Small Group demo: NoYes
Assessment: NoYes
Others:
Session Details :

Timing Details

Choices of Date(s) for the Session *
From:
To:
From:
To:
From:
To:
Timing for the Session
Full Day:
Half Day:
Anticipated number of attendees/participants

Space Requested for Your Session

Outpatient:
EROPD 1OPD 2Nurses stationMock Pharmacy
Diagnostics:
LaboratoryU/S suiteCT/X-ray console roomImaging room- for X-ray/CT
Inpatient:
General WardNICUICUOTOBG Suite
Teaching/Learning Spaces:
Lecture HallSGL Room 1SGL Room 2SGL Room 3SGL Room 4Assessment Hall
Control rooms:
Control room 1-(ICU/OBG)Control room 2-(6 stations)
Life Support Training:
Life Support Training / debriefing room

Equipments

Name
Specifications
Quantity
Projector
TV
Computer
Microscope
X-ray viewer
Others

Instruments

Name
Specifications
Quantity
Additional Details:

Disposable

Name
Specifications
Quantity
Additional Details: