NEW PATIENT REGISTRATION FORM
MR No. Date
If the patient has
a ____________________ card number
(taken in OPD/Health Check up/Casualty/Admission) please DO NOT fill this form,
kindly inform the counter staff to
find your MR number.
Patient Name Father/
Husband Name
Age Sex Date of Birth Mobile
Residential Address
Consultant Name
Referring Doctor Name
I understand that my medical record
will be destroyed 3 years after my last visit to this hospital.
Patient Name Signature
GENERAL
CONSENT
1. I/ We agree for
the patient to undergo examination, investigations and treatment as decided by
the hospital and also to abide by its schedule of charges, rules and
regulations (available at registration counter).
2. I authorize
Mr./Ms. to
take decision on my behalf in case of my inability to do so due to associated
medical condition.
3. I understand
that I have to disclose my clinical history and other relevant information to
the healthcare provider team required for the management of my disease.
4. I am fully aware
that the medical treatment may be extended beyond the expected period at the
discretion of the doctor.
5. If my financial
credit status is disputed by credit/insurance company/TPA, I undertake to
settle the final bill on the date of discharge. I also undertake to make
payment against interim bills raised within stipulated time.
6. The doctor’s
discretion shall be considered as final for my discharge. I assent for transfer
out from your hospital to other hospital/ nursing home in case of non-payment
of bill/ discretion of doctor.
7. I certify that I
read the above and understand the contents. I further state that I have been
given an opportunity to ask questions and all my questions have been answered
fully and to my satisfaction.
Patient/ Relative
Name Relationship
Signature Date
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