Hospital admission can be a stressful process, with lots of paperwork involved. Have you ever been confused by the hospital admission form and wondered why all of these questions need to be answered? Don't worry; we have you covered! In this blog post, we’ll discuss everything you need to know about hospital admissions forms. So make sure to read on if you would like more information on how to efficiently complete your own hospital admission form without feeling overwhelmed.
Question | Answer |
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Form Name | Hospital Admission Form |
Form Length | 1 pages |
Fillable? | No |
Fillable fields | 0 |
Avg. time to fill out | 15 sec |
Other names | hospital memorandum of transfer form, hospital forms services, memorandum or transfer, hospital callback forms |
IF YOU HAVE ANY QUESTIONS, |
DAMERON HOSPITAL ASSOCIATION |
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525 West Acacia Street • Stockton, California 95203 |
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PLEASE CALL: |
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PHONE |
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THIS IS A NON - SMOKING FACILITY |
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Dear Patient, |
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Your doctor’s office has informed us that you are scheduled for surgery on ______________________________________________________ .
So that we may admit you to your room without unnecessary delay we would appreciate your completing this
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PLEASE RETURN FORM IMMEDIATELY |
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Doctor __________________________________________ |
Date due in hospital |
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OB |
Surgery |
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I. PATIENT INFORMATION |
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OB Maiden Name ______________________________________________ |
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Date of |
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Name ________________________________________________ |
Previous Admission ______________________________________ |
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LAST |
FIRST |
MIDDLE |
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(UNDER WHAT NAME) |
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Street Address _____________________________________________________________________ |
Phone _____________________ |
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NUMBER AND STREET |
CITY |
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STATE |
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Mailing Address ____________________________________________________________________ |
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NUMBER AND STREET |
CITY |
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STATE |
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Sex ______ |
Birthdate_________________ |
Age_________ |
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Married; |
Single; |
Widowed; |
Separated; |
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Divorced |
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Birthplace (State) ____________________ |
Religion _______________________ |
Social Security No. ___________________________ |
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Employer ___________________________ |
Occupation _________________ |
How long with present Employer? __________________ |
Employer’s Address _________________________________________________________________ Phone ______________________
NUMBER AND STREET |
CITY |
ZIP |
Were you a patient in any other hospital within the last six months? __________________________________________________________
II. SPOUSE OR NEAREST RELATIVE |
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Name ________________________________________________ |
Relationship ___________________ |
Phone _________________ |
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LAST |
FIRST |
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MIDDLE |
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Address _______________________________________________ |
Social Security Number ___________________ DOB __________ |
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NUMBER AND STREET |
CITY |
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Employer ______________________________________________ |
Occupation ___________________ Birthplace ________________ |
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Employer’s Address _________________________________________________________________ Phone |
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NUMBER AND STREET |
CITY |
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ZIP |
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How long with present employer? _____________________________________________________________________________________
III. IF A PATIENT IS A CHILD, COMPLETE INFORMATION FOR BOTH PARENTS |
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Father ________________________________________________ |
Mother ________________________________________________ |
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LAST |
FIRST |
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MIDDLE |
LAST |
FIRST |
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MIDDLE |
Address _______________________________________________ |
Address _______________________________________________ |
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NUMBER AND STREET |
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CITY |
Date of |
ZIP |
NUMBER AND STREET |
CITY |
Date of |
ZIP |
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Phone ______________ |
SS# ___________ |
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Phone _______________ SS# ____________ |
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Birth |
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Birth |
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Birthplace _____________________________________________ |
Birthplace ______________________________________________ |
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Employer ______________________________________________ |
Employer |
______________________________________________ |
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Employer’s Address _____________________________________ |
Employer’s Address ______________________________________ |
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NUMBER AND STREET |
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CITY |
ZIP |
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NUMBER AND STREET |
CITY |
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ZIP |
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Work Phone no. __________________ |
Occupation __________ |
Work Phone no. ___________________ Occupation __________ |
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How long with present employer? __________________________ |
How long with present employer? ___________________________ |
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IV. INSURANCE INFORMATION |
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Medicare # __________________________ Medical # ______________________ |
Issue Date ____________ |
Kaiser # _______________ |
Primary Insurance _____________________________ ID #_______________________________ Policyholder ________________________
Address and Telephone No. __________________________________________________________________________________________
Secondary Insurance _____________________________ ID #_______________________________ Policyholder ________________
Address and Telephone No. __________________________________________________________________________________________
Worker’s Compensation __________________________________ Address _________________________________________________
Date and Time of Injury _____________________________________________________________________________________________
ADVANCE DIRECTIVES: Have you completed an Advance Directive? |
Yes |
No |
(If yes, please bring a copy for your Medical Record if you have not done this in the past.)
Do you have special needs that we should be aware of? (i.e. language assistance, TTY disability) Please let us know so we can better assist you on your admission: ______________________________________________________________________________________________