Nomination Form - Wellness Clinics

Greetings!

In an endeavor to present to the nation its finest healthcare providers, CNBC-TV18 and ICICI Lombard are

initiating the India Healthcare & Wellness Awards - India's most authoritative awards for the healthcare

industry. Kantar IMRB, India’s leading research agency is powering the robust multi-phase methodology

that will help shortlist India's finest healthcare providers. A panel of the most distinguished names in the

industry and academia will then debate and deliberate to select the final winners across categories.

Please fill the form below to apply into the first phase of the awards.

IMPORTANT:

• Please fill this form only if you are an authorized representative in the senior management team,

administrative head of the wellness clinics. Please note, fill this form only if this is a wellness clinic

• Your wellness clinic needs to meet the following criteria to qualify

Definition:

Homeopathy:- Clinics offering Homeopathy services

Ayurvedic:- Ayurvedic clinics

Wellness clinics (Non-Invasive only):- Clinics specializing in scientific weight management

solutions, skin and haircare treatments, beauty services and personal care

You may nominate your clinic if:

1. Clinic focuses on skin, hair, weight and general wellness management (Spa and beauty services)

through ayurveda, homeopathy and non-invasive techniques

2. Clinic should have branches across more than 1 city OR Clinic should have at least 3 branches in

the city

3. Clinics should be operational for more than 2 years

4. Coverage - Top 6 cities in India (Mumbai, Delhi, Kolkata, Chennai, Bengaluru & Hyderabad)

5. Should not be a hospital

Thank you for your time and participation!

Last date to submit the form is 15th December 2017

1. Please fill out the following details about yourself.

2. Please fill out the following details about your hospital.

3. The following table contains a list of parameters regarding centre capacity (beds/session

rooms/ seating rooms). Please fill in the grid below:

4. The following table contains a list of parameters regarding member turn out at this center.

Please fill in the grid below:

Name .........................................................................................................................................................

Designation ..............................................................................................................................................

Email ID .....................................................................................................................................................

Telephone ......................................................... Mobile .............................................................................

Years worked at current hospital ................................................ Total years of experience .........................

Name of the Homeo/Ayurvedic/Non-invasive Wellness clinic ....................................................................

Inception year ............................................................................................................................................

Address 1 ...................................................................................................................................................

Address 2 ...................................................................................................................................................

Nearest landmark.......................................................................................................................................

City ................................................. State..................................................... Pin Code ..............................

Total no. of clinics across India ...................................................................................................................

List of cities where your wellness clinics are present in India .......................................................................

Total no. of clinics directly operated (owned) ...............................................................................................

Total no. of franchise clinics .......................................................................................................................

Website ......................................................................................................................................................

Wellness clinics category: (Please TICK relevant option):

o Ayurveda o Homeopathy o Non-invasive Wellness

Ownership/legal status: (Please TICK relevant option):

o Proprietorship o Partnership o Private Ltd Firm o Trust/Co-operative o Other

Accreditation for Clinic: (Please TICK relevant option(s)):

o NABH o ISO

o Other (specify):......................................................................................................................................

...................................................................................................................................................................

Number of beds ................. Number of treatment rooms ..................

Total Number of members/ patients in the last year (as per records) ..................

% patients who are walk-in patients (Without long term enrollment for multiple sittings) ..................

% patients who have long term enrollment (For multiple sittings) ..................

% Male patients ..................

% Female patients ..................

5. The following table contains a list of parameters regarding wellness center services. Please

fill in the grid below:

Services:

Ayurveda:

o Abhyangam o Udhvartan o Shirodhara o Patra Pind Swedan o Potli Massage

o Basti o Nasyam

Yoga and physiotherapy:

o Kapalbhati o Yogasan o Meditation o Shankhaprakshalana o Therapeutic Yoga

o Yog Nidra o Shatkarmas o Basti Yoga o Tratak o Power Yoga o Aquatic Yoga

o Physiotherapy o Ultrasound o TENS o Heat Therapy o Shoulder Wheel

o Interferential Current Therapy o Acupuncture

Massages and Spas:

o Vibro Massage o Ion Detox o Soft Tissue Massage o Deep Tissue Message

o Mud Pack o Hydro Therapy o Spine/Foot Bath o Diet Therapy

o Cologne Hydrotherapy o Far Infra Detox o Hot Stone Massage o Reflexology

o Steam o Sauna

Weight management solutions:

o Ultra Sound Liposuction o Thermal Massage o Hot Belt therapy o Cupping Therapy

o Homeopathy Diet Supplementation o Diet and Nutrition Advice

Hair Care Solutions:

o Hair and Skin Therapy o Laser Treatment for Hair Growth o Special Hair Spa

o Hair Massages

Skin Care Solutions:

o Laser Hair Removal o Laser Skin Lightening o Laser Treatment for Acne Break Outs

o Skin Peel/Packs

Others:

Please Specify-

1............................................................................................................................................................

2............................................................................................................................................................

3............................................................................................................................................................

4............................................................................................................................................................

5............................................................................................................................................................

6............................................................................................................................................................

7............................................................................................................................................................

8............................................................................................................................................................

9............................................................................................................................................................

10. Please list the specialties treated and surgery volumes last month.

7. Please list any awards or recognition your wellness clinic has won in the last 2 years

Other hospital staff information Nos Minimum

Educational

Qualification

Qualified Doctors (Homeopathy/Ayurveda Doctors)

Specialized Staff (Dieticians/Physiotherapist/Nutritionist, etc.)

Certified Therapists (Masseurs/Acupuncture Specialists, etc.)

Non-certified Therapists (Masseurs/Acupuncture Specialists, etc.)

Managerial/Administration/Accounts/HR/Marketing Legal etc.

Technician specialized to manage machines like laser, ultrasound, etc.

Other (specify)

Name of Accreditation / Award won Year

Please send in your completed form to:

Ms. Chhaya Jadhav, TV18 Broadcast Ltd., Empire Complex, 1st Floor 414, Senapati Bapat Marg, Lower Parel, Mumbai 13.

Contact - email us at healthrsvp@nw18.com or log on to www.firstpost.com/ihcwa

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