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    Admission Booking Form, Rev. 8

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    Eking In
    This document is an admission booking form for a patient requiring surgery or a special procedure. It requests information such as the patient's name, contact details, nationality, diagnosis, allergies, payment method, planned procedure details including date, anesthesia type and estimated length of admission. Sections for the surgeon's details, pre-procedure verification of privileges and operating theater confirmation are also included. The form must be faxed with required information and documents for the booking to be processed.

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    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd

    Admission Booking Form, Rev. 8

    Uploaded by

    Eking In
    55 views1 page
    This document is an admission booking form for a patient requiring surgery or a special procedure. It requests information such as the patient's name, contact details, nationality, diagnosis, allergies, payment method, planned procedure details including date, anesthesia type and estimated length of admission. Sections for the surgeon's details, pre-procedure verification of privileges and operating theater confirmation are also included. The form must be faxed with required information and documents for the booking to be processed.

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    Admission Booking Form, Rev. 8 (4)

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    This document is an admission booking form for a patient requiring surgery or a special procedure. It requests information such as the patient's name, contact details, nationality, diagnosis, allergies, payment method, planned procedure details including date, anesthesia type and estimated length of admission. Sections for the surgeon's details, pre-procedure verification of privileges and operating theater confirmation are also included. The form must be faxed with required information and documents for the booking to be processed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    55 views1 page

    Admission Booking Form, Rev. 8

    Uploaded by

    Eking In
    This document is an admission booking form for a patient requiring surgery or a special procedure. It requests information such as the patient's name, contact details, nationality, diagnosis, allergies, payment method, planned procedure details including date, anesthesia type and estimated length of admission. Sections for the surgeon's details, pre-procedure verification of privileges and operating theater confirmation are also included. The form must be faxed with required information and documents for the booking to be processed.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    of 1

    ADMISSION BOOKING FORM

    FAX TO: +971-4-3461796


    THIS BOOKING WILL NOT BE PROCESSED WITHOUT THE FOLLOWING INFORMATION

    REASON FOR BOOKING:  SURGERY  SPECIAL PROCEDURE


    SURGEON: _____________________________________________________________________________________________
    PATIENT DETAILS:
    FULL NAME OF THE PATIENT: ________________________________________________________________________________________
    ADDRESS: ___________________________________________________________________________________________________________
    NATIONALITY: SEX: Male Female DOB: ( / / ) dd/mm/year
    MOBILE NUMBER: _____________________________ RESIDENCE NUMBER: ________________________________________

    BRIEF CLINICAL DETAILS


    DIAGNOSIS: _________________________________________________________________________________________________
    ALLERGY: __________________________________________________________________________________________________
    CHRONIC DISEASES: No Diabetes MellitusAsthma Hypertension Hyperthyroidism CAD Osteoporosis
    Hypothyroidism Rheumatoid Arthritis Others _________________________________________
    ANY OTHER PATIENT’S SPECIAL DETAILS TO BE CONSIDERED: ______________________________________________________________

    PAYMENT METHOD:
    INSURANCE (Please Specify Name of Insurance Company) _______________________________________________________
    (Please contact BEH Insurance Department for clarification and arrangement, Telephone numbers: 04-3454000 ext. 1026
    or 2003. Fax number: 04-3453630)
    SELF PAYING SURGEON’S ACCOUNT

    PROCEDURE DETAILS:
    PROCEDURE/SURGERY PLANNED: _____________________________________________________________________________
    DATE OF SURGERY: _____________________________________ ANESTHESIA TYPE: ______________________________________________
    ESTIMATED LENGTH OF SURGERY: __________________________ ESTIMATED LENGTH OF ADMISSION: __________________________
    INVESTIGATION(S) TO BE DONE: ___________________________________________________________________________________________
    SPECIAL EQUIPMENT / SUPPLY NEEDED: ___________________________________________________________________________________
    ANY ORDERS PLEASE MENTION HERE: _____________________________________________________________________________________
    ________________________________________________________________________________________________________________________
    SIGNATURE AND STAMP OF THE SURGEON AND/OR CLINIC
    * Please attach patient’s valid ID copy or passport copy and valid
    insurance card copy.

    TO BE FILLED BY BEH STAFF


    VERIFICATION OF PRIVILEGES
    DOCTOR HAS APPROVED PRIVILEGES FOR THE SURGERY PLANNED/BOOKED.  Yes  No

    VERIFIED BY: ___________________________________________ _________________________________________________


    IPD NURSING SUPERVISOR SPECIALIST ANESTHETIST
    O.T. CASE CONFIRMATION
    SURGERY CONFIRMED DATE: ___________________________________ TIME: __________________________________________________
    CONFIRMED BY: DATE: _________________________________________________
    O.T. CASE CANCELLATION AND RESCHEDULE
    REASON FOR CANCELLATION: ____________________________________________________________________________________________
    ________________________________________________________________________________________________________________________
    CANCELLED BY: DATE: _________________________________________________
    RESCHEDULE NEEDED: NO YES ~ TO DATE & TIME: _______________________________________________________________
    CONFIRMED BY: DATE: _________________________________________________

    Date of Last Revision: 08/04/2017 BEH-FM-63, Rev. 8

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