Hospital Admission Form PDF Details

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.

QuestionAnswer
Form NameHospital Admission Form
Form Length1 pages
Fillable?No
Fillable fields0
Avg. time to fill out15 sec
Other nameshospital memorandum of transfer form, hospital forms services, memorandum or transfer, hospital callback forms

Form Preview Example

IF YOU HAVE ANY QUESTIONS,

DAMERON HOSPITAL ASSOCIATION

525 West Acacia Street • Stockton, California 95203

PLEASE CALL: 461-3141 / FOR SHORT STAY: 461-3183

PHONE 944-5550

THIS IS A NON - SMOKING FACILITY

PRE-ADMISSION INFORMATION

 

Dear Patient,

 

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 pre-admission form and returning it to us. Please be sure the information provided is accurate and given in detail, particularly all insurance, Medi-Cal, or Medicare numbers. This will enable us to have all your admission papers typed and ready for your signatures upon your arrival at the hospital. Please DO NOT bring jewelry or valuables to the hospital. We strive to provide the type of room requested, but we cannot guarantee this.

 

PLEASE RETURN FORM IMMEDIATELY

 

 

 

Doctor __________________________________________

Date due in hospital

__________________________

OB

Surgery

I. PATIENT INFORMATION

 

OB Maiden Name ______________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

Date of

 

 

 

 

 

 

Name ________________________________________________

Previous Admission ______________________________________

LAST

FIRST

MIDDLE

 

 

 

 

(UNDER WHAT NAME)

 

 

Street Address _____________________________________________________________________

Phone _____________________

 

NUMBER AND STREET

CITY

 

STATE

 

 

ZIP

 

 

 

Mailing Address ____________________________________________________________________

 

 

 

 

NUMBER AND STREET

CITY

 

STATE

 

 

ZIP

 

 

 

Sex ______

Birthdate_________________

Age_________

 

Married;

Single;

Widowed;

Separated;

 

Divorced

Birthplace (State) ____________________

Religion _______________________

Social Security No. ___________________________

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

 

 

 

Name ________________________________________________

Relationship ___________________

Phone _________________

LAST

FIRST

 

MIDDLE

 

 

Address _______________________________________________

Social Security Number ___________________ DOB __________

NUMBER AND STREET

CITY

ZIP

 

 

Employer ______________________________________________

Occupation ___________________ Birthplace ________________

Employer’s Address _________________________________________________________________ Phone

______________________

 

NUMBER AND STREET

CITY

 

ZIP

 

How long with present employer? _____________________________________________________________________________________

III. IF A PATIENT IS A CHILD, COMPLETE INFORMATION FOR BOTH PARENTS

 

Father ________________________________________________

Mother ________________________________________________

LAST

FIRST

 

 

MIDDLE

LAST

FIRST

 

 

MIDDLE

Address _______________________________________________

Address _______________________________________________

NUMBER AND STREET

 

CITY

Date of

ZIP

NUMBER AND STREET

CITY

Date of

ZIP

Phone ______________

SS# ___________

 

Phone _______________ SS# ____________

 

 

 

 

Birth

 

 

 

 

Birth

 

Birthplace _____________________________________________

Birthplace ______________________________________________

Employer ______________________________________________

Employer

______________________________________________

Employer’s Address _____________________________________

Employer’s Address ______________________________________

NUMBER AND STREET

 

CITY

ZIP

 

NUMBER AND STREET

CITY

 

ZIP

Work Phone no. __________________

Occupation __________

Work Phone no. ___________________ Occupation __________

How long with present employer? __________________________

How long with present employer? ___________________________

IV. INSURANCE INFORMATION

 

 

 

 

 

 

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: ______________________________________________________________________________________________

8560-186 (4/24/07)