Name as shown in NRIC/Passport (Dr/Mr/Mrs/Miss/Mdm*)
1.3
Male/Female
1.7
NRIC/Passport No.
1.2
Residential Address
1.4
Home Tel No.
1.8
Office Tel No.
1.5
Mobile/Pager No
1.9
Email Address
1.6
MCR No.
1.10
Qualifications
SECTION 2 — PARTICULARS OF PREMISES
2.1
Name of healthcare institution (as shown in the licence issued under the Private Hospitals and Medical Clinics Act (Chapter 248))
2.2
Tel No.
2.3
Fax No.
2.4
Address of healthcare institution (as shown in the licence issued under the Private Hospitals and Medical Clinics Act (Chapter 248))
SECTION 3 — PARTICULARS OF PERSONNEL
3.1
Name of medical practitioners authorised to perform abortion
MCR No.
Type of Registration
Qualifications
(1)
Full/Conditional
(2)
Full/Conditional
(3)
Full/Conditional
(4)
Full/Conditional
(5)
Full/Conditional
3.2
Name of anaesthetists
MCR No.
Type of Registration
Qualifications
(1)
Full/Conditional
(2)
Full/Conditional
(3)
Full/Conditional
(4)
Full/Conditional
3.3
Name of trained nurses
Qualifications
(1)
(2)
(3)
3.4
Name of certified Termination of Pregnancy counsellors
Qualifications
(1)
(2)
SECTION 4 — FACILITIES AND EQUIPMENT
Item
Total Number
(a)
Recovery beds
(b)
Major and Minor Operating Theatres
(c)
Operating tables
(d)
Operating lights (fixed and portable)
(e)
Motor suction
(f)
Instrument trolley
(g)
Instrument/dressing cabinet
(h)
Are there facilities for sterilisation of instruments
Yes/No
(i)
Alternate light source in the event of power failure
Yes/No
SECTION 5 — STATISTICS ON ABORTION (for renewal only)
Number of abortions performed during the previous 2 years
Year
__________
Year
__________
__________
__________
SECTION 6 — DECLARATION
I declare the information in my application to be true, to the best of my knowledge. I also understand that approval of the licence is dependant on satisfactory compliance with the relevant requirements under the Termination of Pregnancy Act, Regulations and Guidelines.
Please note that MOH will contact you, if we require any additional information for your licence application.
*Delete where necessary.
FORM II
Regulation 3 (5)
TERMINATION OF PREGNANCY ACT (CHAPTER 324)
TERMINATION OF PREGNANCY REGULATIONS
APPLICATION FOR AN AUTHORISATION TO CARRY OUT TREATMENT TO TERMINATE PREGNANCY
Application is hereby made by
_____________________________
(Insert name of medical practitioner)
of ___________________________
at ___________________________
(Insert name of hospital/clinic)
(Insert address of hospital/clinic)
for an authorisation to carry out treatment to terminate pregnancy under *regulation 3 (1) or 3 (2) of the Termination of Pregnancy Regulations.
Particulars of Applicant
My qualifications and Obstetric and Gynaecological experience are as follows:
(1)
Medical Qualifications:
(2)
Duration of Obstetric and Gynaecological experience in Singapore Government hospital (excluding housemanship):
(3)
Duration of Obstetric and Gynaecological experience in other hospitals (excluding housemanship):
*Delete whichever is inapplicable.
Declaration
I hereby declare that the particulars stated in this application and the attached documents listed below are true to the best of my knowledge and belief.
Documents submitted [Mark ‘X’ in the appropriate box(es)]
1.
A copy each of my medical qualifications
2.
Proof of my Obstetric and Gynaecological experience
3.
Others:
____________________
____________________
Date
Signature of Applicant
CONFIDENTIAL
FORM III
Regulation 6 (2)
TERMINATION OF PREGNANCY ACT (CHAPTER 324)
TERMINATION OF PREGNANCY REGULATIONS
CONSENT FOR THE TREATMENT TO TERMINATE PREGNANCY
I have been counselled by ______________________________________
and fully understand the effects of abortion. I hereby request and give my consent for treatment to terminate pregnancy to be performed on me by
of ____________________________________________________________
(Hospital/Approved Institution)
at ____________________________________________________________
(Address)
I also consent to such further alternative operative measures as may be found necessary during the course of the operation and to the administration of anaesthesia for this purpose.
Name of Pregnant Woman: _______________________________________
I hereby declare that the above information given by me is true and correct.
________________
___________________________
Date
Signature of Declarant
FORM V
Regulation 8
TERMINATION OF PREGNANCY ACT (CHAPTER 324)
TERMINATION OF PREGNANCY REGULATIONS
RETURN ON PROVISION FOR TERMINATION OF PREGNANCY COUNSELLING FACILITIES AT CLINIC
I _____________________________________________________________
(Name of Authorised Medical Practitioner)
of _________________________________________________________________
(Name and Address of Clinic)
Hereby declare that the personnel and facilities indicated hereunder are available for counselling:
1.
Hospital/Clinic where pre and post-termination of pregnancy counselling will be provided: __________________________________________________ __________________________________________________
2.
Counsellors:
Name
Qualifications
_________________________
____________________
_________________________
____________________
_________________________
____________________
3.
Audio-visual equipment for screening of counselling materials:
(a)
Number of television sets: ______________________
(b)
Number of video cassette recorders: ______________
I am prepared to give all facilities to any public officer at the Ministry of Health to enter and inspect my clinic and to answer any questions that may be put to me.