Layxud&Fpfdrlk Izfriwfrz Okmplz Ewy:Ik Eseq0& 192950&00 Ek DK Dqy& Iuus Hkonh

izs’kd%
[k.M fodkl vf/kdkjh

pjxkWOkk&xksj[kiqj
Lksok esa
ftyk fodkl vf/kdkjh
Xkskj[kiqj
Ik=kad% @LFkk0@fpfdRlk@izfriwfrZ@20&21@fnukad%&
Ekgksn;
bl fodkl [k.M dk;kZy; esa dk;Zjr Jh vouh”k dqekj mik/;k; ys[kkdkj us vius ekrk
th Jherh fo+|k nsoh iRuh Lo0 vH;kpj.k mik/;k ds fpfdRlk ij gqos O;; dk fpfdRlk O;;
izfriwfrZ okmplZ eq0&192950 ¼,d yk[k ckucs gtkj ukS lkS ipkl) ek= dk ewy :Ik esa
izfriwfrZ ds Hkqxrku gsrq ifjf”k’V &x ij iw.kZ dj ,oa lacf/kr fpfdRld ls gLrk{kfjr
djkdj ,oa izekf.kr djkdj ewy:I es bl dk;kZy; es izkIr djk;k x;k gS! ftls bl i= ds lkFk
layXu dj vkidh lsok ess lknj ,oa vko”;d dk;Zokgh gsrq izsf’kr gS !
layXud&fpfdRlk izfriwfrZ okmplZ

ewy:Ik eseq0&¼192950&00½ek= dk
dqy& iUus Hkonh;
[k.M fodkl vf/kdkjh

pjxkWok&xksj[kiqj
ifjf”k’V ¼x½
¼Hkkx & ikpW&fu;e&16 rFkk 18 ns[ksa½
lsokesa]
dk;kZy;k/;{k dk uke
----------------------------------------------
-----------------------------------------------
fo’k;^& fpfdRlk mipkj ij fd;s x;s O;; dh izfriwfrZ A
egksn;]
eS --------------------------------------@esjs ifjokjhd lnL; dk

¼uke½-----------------------------------------
---------------------------us----------------------------------¼chekjh dk uke½ ds
fy;s--------------------------------------------------------------
fnukad----------------------ls-------------------------rd ¼fpfdRlky; dk
uke½------------------------------------------------------------
---------------------------------------------------------------esa mipkj djok;k gS A eSa
fuEufyf[kr nLrkostksa ds lkFk
aeq0--------------------------dh izfriwfrZ ds fy;s nkok izLrqr dj jgk gwW A
1& fpfdRlky; ds jksx fo”ks’kK }kjk gLrk{kfjr@izfrgLrk{kjh vfuok;Zrk

izek.k i= A
2& mipkjh fpfdRld }kjk fof/kor gLrk{kfjr ,oa lR;kfir ewy udn iphZ ¼dS”k
eseksa½
fctd ¼fcy½ ckmpj A
3& ;g izekf.kr fd;k tkrk gS fd Åij ukfer ikfjokjhd lnL; eq> ij iw.kZr;k vkfJr
gS A
esjs mipkjkFkZ--------------------------------ds i=
la0-----------------------------------------fnukad------------------}kjk Lohd`r :
0--------------------------------------ds vfxze dk lek;kstu djus ds i”pkr esjs nkos dh
izfriwfrZ ds fy;s ;Fkk vko”;d dk;Zokgh djus dh dìk djsa A
fnukad&--------------
vf/kdkjh@deZpkjh dk in uke&
inuke&------------------------------------
rSukrh dk LFkku&---------------------
vfuokZ;rk izek.k i=
izekf.kr fd;k tkrk gS fd

Jh@Jherh-------------------------------------------------------------------------jksx ls
ihfMr gksus ds dkj.k mudh fpfdRlk fnukad-------------------ls----------------------rd
esjs funsZ”k ds dze esa fd;k x;k gS A
Mk0 dk gLrk{kj@eqgj
Certify that Mrs./Mr/Miss------------------------------------------------------
CR. No--------------------Wife/Son/Daughter Of Mr-------------------------Employ In
The---------------------------------------------------------------------
CERTIFICATE- ‘A’
[To be completed in the case of patient who are not admitted in hospital for
treatement ]
1-Dr------------------------------------------hereby certify-
[a]- That I Charged/received Rs----------------------for administering
--------------------------at my---------------------------consulting room/at the Residence of
the patient.
[b]-That I charged and received Rs-------------------- for administering
Intramuscular/ subcutaneous injections on-------------------------at
My consulting room/at the residence of the patient.
[c]-That the patient has been under treatement at---------------hospital/my consulting
room and that the under mentioned medicines prescribed by me in this connection
were essential for the
recovery/preventionof serious detcriation in thecondition of the patient. The
medicines are not stocked in the [ Name of Hospital]
for the supply to private patient and do not enclude proprietary preperations for which
chaper substances of equal therapeytio value are available not preparations which are
primarily foods, toilets, and disinfectants.
Jh vouh”k dqekj mik/;k; ys[kkdkj }kjk vius viuh iRuh Jherh mek
mik/;k; ds fpfdRlk O;; ij gqos izfriwfrZ dk
enokj fooj.k& fodkl [k.M ljnkjuxj xksj[kiqj
D Lkaca
l ds ;g
inu lEcU/k fpfdRld dk uke ,oa irk x;h fp
a ke
fpfdRlk djkus /kujk
okyss O;fDr dk
uke
1 Jherhmek mik/;k; & iRuhJhvouh”k dqekj
Mk0 &
mik/;k; jktu ],echch,l]vkFkks
Ysk[kkdkj Z
fodkl[k.M&ljnkjuxj Ekksgnhiqj&xkasj[kiq
xksj[kiqj j
Mk0 v”kkssd ;kno
2 Jherhmek mik/;k; iRuhJhvouh”kdqekjm Mk0 v”kkssd ;kno

& ik/;k; ,e0ch0ch0,l0 vkFkksZ] ]
Ysk[kkdkj U;w mn;k esfMdy izk0fy0
fodkl[k.M&ljnkjuxj xkW/kh xyh xksy/kj]
xksj[kiqj xksj[kiqj
3 Jherhmek mik/;k; iRuhJhvouh”k dqekj

Mk0 iou dqekj flag]
& mik/;k; ,echch,l]Mh,e]&U;wj
Ysk[kkdkj ksykth
fodkl[k.M&ljnkjuxj jkIrhuxj]
xksj[kiqj pjxkWok]xksj[kiqj
Dqy ;ksx&
uksV%&1& mijksDrkuqlkj lHkh dS”kesekas izkFkhZ }kjk gLrk{kfjr esfMsdy izi= ds lkFk layXu gS !
eq&¼ ½
2&izkFkhZ dh iRuh dh fpfdRlk lacf/kr fpfdRld ds ;gkW py jgh gS ,oa vHkh fpfdRlk cUn ugh gqbZ gS !
bl gsrq izkFkhZ }kjk izek.k i= layXu dj fn;k x;k gS !
izkFkhZ dk gLrk{kj
uke& vouh”k dqekj mik/;k;
in&ys[kkdkj
fodkl[k.M&ljnkjuxj&xksj[kiqj
Izkek.k i=
Lkasok es
Jh eku [k.M fodkl vf/kdkjh
Lkjnkjuxj xksj[kiqj
Ekgkasn;
Lkknj fuosnu gsssss fd izkFkhZ dh Lo;a dh fpfdRlk @esfMdy fVzVeasV

Mk0& ,e0ch0ch0,l0] ,e0Mh0] nkmniqj xksj[kiqj es ds ;gkW py jgk gS
vHkh esfMdy VhzZVesV cUn ugh gqqvk gS! ftlds lkiss{k @ otg ls esfMdy
VhzVesaV ds fizLdÌlu dh Nk;kizfr layXu dh x;h gS !
izkFkhzZ dk uke& vouh”k dqekj mik/;k;
in& ys[kkdkj& fodkl [k.M] ljnkjuxj
xksj[kiqj fnukWd&
Izkek.k i=
Lkasok es
Lkjnkjuxj xksj[kiqj
Ekgkasn;
Lkknj fuosnu gsssss fd izkFkhZ dh iRuh Jherh mek mik/;k; dh fpfdRlk

@esfMdy fVzVeasV U;w mn; esfMdy LksUVj izk0fy0&xkW/kh xyh xkssy/kj
xksj[kiqj es Mk0&v”kksd ;kno] ,e0ch0ch0,l0] ,e0,l0] vkFkksZ0 xkW/kh xyh
xksy/kj xksj[kiqj ds ;gkW py jgk gS vHkh esfMdy VhzZVesV cUn ugh gqqvk
gS! ftlds lkiss{k @ otg ls dsoy esfMdy VhzVesaV ds fizLdÌlu dh Nk;kizfr
layXu dh x;h gS !
xksj[kiqj fnukWd&
Izkek.k i=
Lkasok es
Lkjnkjuxj xksj[kiqj
Ekgkasn;
Lkknj fuosnu gsssss fd izkFkhZ ekrk Jherh fo|k nsoha dh fpfdRlk @esfMdy
fVzVeasV Mk0& ,e0ch0ch0,l0] ,e0Mh0] nkmniqj xksj[kiqj es ds ;gkW
py jgk gS vHkh esfMdy VhzZVesV cUn ugh gqqvk gS! ftlds lkiss{k @ otg ls
esfMdy VhzVesaV ds fizLdÌlu dh Nk;kizfr layXu dh x;h gS !
xksj[kiqj fnukWd&
Izkek.k i=
Lkasok es
Lkjnkjuxj xksj[kiqj
Ekgkasn;
Lkknj fuosnu gsssss fd izkFkhZ ds iq= lfpu dqekj mik/;k; dh fpfdRlk

@esfMdy fVzVeasV Mk0& ,e0ch0ch0,l0] ,e0Mh0] nkmniqj xksj[kiqj es
ds ;gkW py jgk gS vHkh esfMdy VhzZVesV cUn ugh gqqvk gS! ftlds lkiss{k
@ otg ls esfMdy VhzVesaV ds fizLdÌlu dh Nk;kizfr layXu dh x;h gS !
xksj[kiqj fnukWd&
Lksok es
Jheku [k.M fodkl vf/kdkjh
Lkjnkjuxj xksj[kiqj
fo’k;& izkFkhZ dh iRuh Jherh mek mik/;k; ds fpfdRlk ij gqos

O;; dh izfriwfrZ ds Hkqxrku izzkFkhZ dks djus ds lac/k es %&
Ekgksn;]
Lkknj fuosnu djuk gS fd izkFkhZ }kjk viuh iRuh Jherh mek mik/;k; dh
fpfdRlk xksj[kiqj “kgj dss fpfdRldks dss ;gk djk;k tk jgk gS ftl ij izkFkhZ }kjk
Lo;a vius O;; ij eq0&
&00¼ ek=½ dk fpfdRlk O;; fd;k x;k gS ftldh izfriwfrZ dk
Hkqxrku izkFkhZ dkss fd;k tkuk gS ] ftldh fpfdRlk izfriwfrZZ dh dS”keseks
Lo;a ,oa fpfdRldx.k ls djkdj ,oa nok dk fiz”dÌ”ku]tkWp fjiksssVZ]izzek.k i=
vkfn bl i= dss lkFk ewy:i@Nk;kizfr dsss lkFk layXu dj vkidssss ikl Hkqxrku
gsrq lknj izsf’kr gS !
vr% vki egkssn; ls lknj vuqjks/k gS fd mijksDrkuqlkj fpfdRlk O;;
izfriwwfrZ dk Hkqxrku izkFkhZ dks djkus dk d’V djsA
layXud& fpfdRlk O;; izfriwfrZ okmplZ dqy& iUus ek=

eq0&
ek= dk ewwy:Ik es
izkFkhZ dk gLrk{kj
uke&
in& fnukWd&

Layxud&Fpfdrlk Izfriwfrz Okmplz Ewy:Ik Eseq0& 192950&00 Ek DK Dqy& Iuus Hkonh

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Layxud&Fpfdrlk Izfriwfrz Okmplz Ewy:Ik Eseq0& 192950&00 Ek DK Dqy& Iuus Hkonh

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Layxud&Fpfdrlk Izfriwfrz Okmplz Ewy:Ik Eseq0& 192950&00 Ek DK Dqy& Iuus Hkonh

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izs’kd%

[k.M fodkl vf/kdkjh

layXud&fpfdRlk izfriwfrZ okmplZ

[k.M fodkl vf/kdkjh

eS --------------------------------------@esjs ifjokjhd lnL; dk

1& fpfdRlky; ds jksx fo”ks’kK }kjk gLrk{kfjr@izfrgLrk{kjh vfuok;Zrk

izekf.kr fd;k tkrk gS fd

2 Jherhmek mik/;k; iRuhJhvouh”kdqekjm Mk0 v”kkssd ;kno

3 Jherhmek mik/;k; iRuhJhvouh”k dqekj

Jh eku [k.M fodkl vf/kdkjh

Lkknj fuosnu gsssss fd izkFkhZ dh Lo;a dh fpfdRlk @esfMdy fVzVeasV

izkFkhzZ dk uke& vouh”k dqekj mik/;k;

in& ys[kkdkj& fodkl [k.M] ljnkjuxj

Jh eku [k.M fodkl vf/kdkjh

Lkknj fuosnu gsssss fd izkFkhZ dh iRuh Jherh mek mik/;k; dh fpfdRlk

izkFkhzZ dk uke& vouh”k dqekj mik/;k;

in& ys[kkdkj& fodkl [k.M] ljnkjuxj

Jh eku [k.M fodkl vf/kdkjh

izkFkhzZ dk uke& vouh”k dqekj mik/;k;

in& ys[kkdkj& fodkl [k.M] ljnkjuxj

Jh eku [k.M fodkl vf/kdkjh

Lkknj fuosnu gsssss fd izkFkhZ ds iq= lfpu dqekj mik/;k; dh fpfdRlk

izkFkhzZ dk uke& vouh”k dqekj mik/;k;

in& ys[kkdkj& fodkl [k.M] ljnkjuxj

Jheku [k.M fodkl vf/kdkjh

fo’k;& izkFkhZ dh iRuh Jherh mek mik/;k; ds fpfdRlk ij gqos

layXud& fpfdRlk O;; izfriwfrZ okmplZ dqy& iUus ek=

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