Accommodation Request
Instructions: Patient Identification:
1. Please write or type information
2. Give this accommodation form to patient and forward him/her to admission Patient Full Name: ___________________
office
3. Doctors are requested to generate Admission Request in system along with OR ___________________________________
request in case of Surgical Procedure.
4. Admission office is requested to Scan and update accommodation form on Medical Record #: ____________________
HIMS.
Gender: Male Female
PLEASE NOTE Illegible, Incorrect and/or incomplete information does delay the Date of Birth/Age: ____________________
admission process!
Admission Data
(To be completed by Physician)
1. Admitting physician __________________ Contact # / Ext. _____________
2. Referring physician __________________ Contact # / Ext. _____________
3. Provision diagnosis at
time of admission _________________________________________________________________
4. Proposed date 5. Reporting time in 6. Estimated length
of admission __________________ admission office ______________ of stay ________ days
7. Surgical Procedure
Planned (if any) ___________________________________________________________________
8. Proposed date 9. Type of care
of Surgery ________________ requested ( ) PR ( ) HDU ( ) Isolation ( ) WD
10. Status Inpatient: ( ) Day Surgery: ( )
_________________ __________________
(Physician Signature) (Date)
Admission Office
11. Total Estimation ___________________________ 12. Initial Deposit Required Rs. __________________
13. Initial Deposit Required Rs. __________________
___________________ ______________ __________________________
(FDO Admission Office) (Date) Patient Acknowledgement (Sign)
Note: Cost estimation can increase during treatment due to complex diseases treatment, number of diagnostic tests performed,
medicines or extended stay required for treatment at hospital.
