PATIENT COUNSELLING

Patient Name : Date :

Doctor Name : UHID No :

Admission Date : Room Rent :

Expected Discharge Date :

Procedure/Package Charges :
Procedure/Package Name :

Room Category :

Implant Cost :
Payment : Cash/Credit/Insurance :

Name of the Payer

Any Special Needs

Remarks Total Estimated Expenses :

FOE Signature :
I/We have understand everything explained to me I guarantee to adhere by the hospital policy/schedule of charges
against my patient medical requirement/consumption & hence take full responsibility of clearing bill and balance

Signature of Patient / Attendant Relation:

Name of Attendant : Tel No: