Office No 5, Bhosale House Apts, Karve Road, Pune- firstname.lastname@example.org For job inquiries use email@example.com Registration Form(Doctor) 1.Post Applied* ---Physician assistant(Doctors)PhysiotherapistNursesHealthcare attendentLab TechniciansHealthcare ManagersConsultants Upload Your Photo 2. Total Years of Experience Years* ---123456789101112131415161718192021222324252627282930313233343536373839404242434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100 Months ---123456789101112 3. Relevant Experience Years* ---123456789101112131415161718192021222324252627282930313233343536373839404242434445464748495051525354555657585960616263646566676869707172737475767778798081828384858687888990919293949596979899100 Months ---123456789101112 4.Educational Qualification* (A) Applicant Information 5.Date of Birth* 6.Gender Group Male Female 7.Marital Status Married Single (B) Applicant Contact Information 8. Permanent Address District* Tehsil City/ Village* Locality Landmark Pin Code* 9. Residential Address* Same as above District* Tehsil City/ Village* Locality Landmark Pin Code* 10. Contact Details(Mobile Number*) 11.Personal Email ID* (C) Applicant Document,Work Experience & Skill Set Information 12.Official Email ID 13. Do you have Passport? No Yes Applied For 14. If yes Number Date Of Issue Date Of Expiry 15. Registration No 16. Current organization 17. Workplace address 18. Current work Schedule From 12:00am12:30am1:00am1:30am2:00am2:30am3:00am3:30am4:00am4:30am5:00am5:30am6:00am6:30am7:00am7:30am8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm5:30pm6:00pm6:30pm7:00pm7:30pm8:00pm8:30pm9:00pm9:30pm10:00pm10:30pm11:00pm11:30pm To 12:00am12:30am1:00am1:30am2:00am2:30am3:00am3:30am4:00am4:30am5:00am5:30am6:00am6:30am7:00am7:30am8:00am8:30am9:00am9:30am10:00am10:30am11:00am11:30am12:00pm12:30pm1:00pm1:30pm2:00pm2:30pm3:00pm3:30pm4:00pm4:30pm5:00pm5:30pm6:00pm6:30pm7:00pm7:30pm8:00pm8:30pm9:00pm9:30pm10:00pm10:30pm11:00pm11:30pm 19. Names of the hospitals you are affiliated with Sr No Hospital Name City Name Location 1 2 3 20. Bank A/c Details Sr No Area of Information Details 1 Account Holder Name 2 Name of the bank 3 A/C Number 4 Branch Name 5 IFSC Code Note:Please check and fill the Annexure enclosed with form, for more details read guidelines or for help contact reception Annexure-1 Skill Set Chart (√) on skill levels- Write skills from list of Spero home health services list for Sr No Physician Assistant Services – Medical Practitioner Yes No 1 Routine General check-up & Physical 2 examinations (Preventive Check-up) 3 Traditional home visits (Common Ailments) 4 On-going treatment of medical conditions 5 Physician review/consultation for authorization of 6 medical care, nursing care, pharmacy, diagnostics 7 and referral to physical therapy and specialized 8 rehabilitation services 9 Post-Surgical care 10 Ambulation 11 BSL on Glucometer 12 Bladder Wash 13 Bladder Wash (In Situ Cathetor) 14 Bilateral Stitch Removal 15 Catheter removal/insertion/care 16 Colostomy Care 17 Counselling 18 Central line (Advance IV)care and removal 19 Cast - monitoring and removal 20 Condom Cathetor 21 Dressing: Small 22 Dressing: Medium 23 Dressing: Large 24 Doctor Visit with Glucometer 25 Doctor Visit with ECG Machine 26 Glove Drain Catherization 27 ICD care and assessment 28 Insulin injectable 29 ICD Dressing 30 IV infusion care and therapy 31 Injections (IV, IM, SC) 32 Manual Evacuation of Feaces 33 Nebulization therapy 34 Need based Medical Transportation 35 Ongoing-Preventive Care 36 Oxygenation therapy 37 Oxygen therapy 38 Positioning advice 39 PEG care 40 Pain management 41 Routine ECG monitoring 42 RT removal/insertion/care 43 Routine diet management 44 Stoma care 45 Sore care advice 46 Suture/Stapler removal 47 Tracheobronchial Suctioning 48 Services we offer 49 Traction 50 Tube feedings 51 Tracheostomy removal & replacement 52 Unilateral TKR Stitch Removal 53 V-P Shunt care 54 Vitals monitoring (Pulse, BP, SPO2, RR etc) 55 Ventilator support (C-PAP/Bi-PAP) 56 Wound care management & Skin care I hereby declare that the details furnished above are true and correct to the best of my knowledge and belief and I undertake to inform you of any changes therein, immediately. In case any of the above information is found to be false or untrue or misleading or misrepresenting, I am aware that I may be held liable for it. I hereby authorize sharing of the information furnished on this form with the Spero Healthcare Innovations Pvt. Ltd.