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: