KINGDOM OF LESOTHO
MINISTRY OF HEALTH P.O. BOX 514
(+266) 22312836)
APPLICATION FOR A HEALTH FACILITY LICENSE
1) Facility Number 2) District 3) Is this Application (x)
Initial / New application
Renewal
⮚ Practice Number………………
⮚ Upgrade to …………………….
SERVICE INFORMATION
Name of Facility:
Physical Address:
Postal Address:
Business:
Phone Number:
Fax Number:
Manager’s Name: Contact Number:
Technical in charge name: Contact Number:
PROPRIETOR INFORMATION
Name:
Address:
Business Phone Number:
24 Hour Access Number:
1
Business e-mail address:
PARENT OR ASSOCIATED COMPANIES OF OWNER
Name:
Address:
Service Ownership Type
Sole Proprietor / Individual
Partnership Limited
Body Corporate
Other Specify ………………………………………………………….
TYPE OF FACILITY (Tick appropriate box)
Wholesaler
Pharmacy
Chemist
Medicine Outlet Type
Manufacturer
Other (Specify)
Hospital
Maternity Home
Clinic
Nursing Home
Physiotherapy Clinic
Medical Laboratory
2
Other (please specify)
SERVICES (Tick appropriate box)
Medicine Supplier
Medicine Outlet Service Medicine Dispenser
Medicine Production
Medicine Distributer
Outpatient
Under five
Maternal Care
Maternity
Adolescent Care
HTC
ART
TB DOTS
In patients
Intensive Care
Dental Care
Eye Care
Physiotherapy
Medical Laboratory
Other (please specify)
BASIC FURNITURE LIST FOR PRIVATE PRACTICE
Description Quantity
3
Patient chair
Relative chair
Doctor’s chair
Patients sitting
Table with drawers
Dispensing table
PROFESSIONAL STAFF COMPLEMENT
Cadres Numbers Full time Part time
Medical Officer – General Practitioner
Medical Officer – Specialist/Consultant
(Specify) ……………………………….
Dentists
Pharmacists
Nurse Clinicians
Clinical Officers
Midwives
General Nurses
4
Pharmacy Technicians
Physiotherapists
Lab Technologists
Radiographers
Nursing Assistants
Receptionist
Other (Specify)…………………………
FORM B: APPLICATION FOR AUTHORIZATION TO OPERATE A PHARMACY
Who may fill this part?
1. An individual who is applying to operate a pharmacy
2. An agent or employee of a body corporate or partnership
- Make yourself familiar with the provisions of Medical, Dental and Pharmacy Order 1970.
- It is an offence to make a false statutory declaration
- The authority licensing may request an additional information and inspect a facility
FACILITY REGISTRATION DETAILS
- INDIVIDUAL
- PARTNERSHIP
5
- BODY CORPORATE
ADDRESS DETAILS:
- INDIVIDUAL
- PARTNERSHIP
- BODY CORPORATE
REGISTRATION DETAILS
- Date of registration
- Date of incorporation
Board NAME & SURNAME QUALIFICATIONS
- Directors
- Trustees
- Partners
RESPONSIBLE PERSONS
STREET ADDRESS OF
PHARMACY
INTERESTS HELD BY
PRESCRIBERS
6
ELIGIBILITY TO HOLD
AUTHORIZATION
PRACTICES AND
PROCEDURES
Other Pharmacies Operated by:
INDIVIDUAL
PARTNERSHIP
BODY CORPORATE
Please attach the following for the staff:
1. Certified copies of academic certificates for all professional staff.
2. Certified copies of current registration with the relevant professional Council
for all professional staff.
3. Curriculum Vitae for all professional staff.
4. Certified copy, details of architectural drawing of the facility and any
envisaged future expansions.
5. Certificate of facility inspection by the Health Inspector.
6. Copy of Company Extract
7
7. Available equipment and detailed furniture matching minimum standard list
pertaining to the practice applied for as per Annex 1.
I, the undersigned declare that the facility shall be used exclusively for the
purpose (s) stated above.
PROPRIETOR’S Name: ____________________________________________
Signature: ___________________________ Date________________________
