Hospital Admission Form – Fill Out and Use This PDF

The Hospital Admission form is a comprehensive document that patients are required to fill out prior to being admitted to a hospital. It collects crucial information such as personal details, insurance information, medical history, and any specific needs or requests that the hospital should be aware of before the patient's arrival. This process ensures a smoother admission procedure and assists in providing personalized care tailored to the patient's needs. To facilitate your admission, make sure to fill out the form accurately by clicking the button below.

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Hospital Admission Form PDF Details

The journey through hospital admission is guided significantly by filling out the Hospital Admission form, an essential step for patients scheduled for surgery or any medical procedure. Dameron Hospital Association, located at 525 West Acacia Street in Stockton, California, emphasizes the importance of providing complete and accurate personal and medical information through the form to ensure a smooth admission process. This comprehensive form covers personal data, including basic identification details, insurance information, and specifics about the patient’s condition and medical history. It also highlights the necessity of avoiding bringing valuables to the non-smoking facility and acknowledges room requests cannot always be guaranteed. Additionally, it carries sections dedicated to spouse or nearest relative information, details relevant if the patient is a child, and crucial insurance data, encompassing Medicare, Medi-Cal, and private insurance specifics. This form also queries about Advance Directives and special needs like language assistance, reinforcing the hospital's commitment to personalized and attentive care from the moment of admission. It stands as a critical document that bridges patients' preparatory process with the hospital's administrative and healthcare delivery systems, designed to streamline the admission process and ensure a focus on health and recovery.

Question	Answer
Form Name	Hospital Admission Form
Form Length	1 pages
Fillable?	Yes
Fillable fields	48
Avg. time to fill out	9 min 51 sec
Other names	memorandum of transfer form, hospital memorandum of transfer requirements, hospital memorandum of transfer form, psychiatric hospital admission consent form

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	IF YOU HAVE ANY QUESTIONS,	DAMERON HOSPITAL ASSOCIATION
	IF YOU HAVE ANY QUESTIONS,	525 West Acacia Street • Stockton, California 95203
	PLEASE CALL: 461-3141 / FOR SHORT STAY: 461-3183	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
		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 ______________________________________________
I. PATIENT INFORMATION
			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

(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)

Hospital Admission Form – Fill Out and Use This PDF

Hospital Admission Form PDF Details

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