ADMISSION BOOKING FORM

FAX TO: +971-4-3461796

THIS BOOKING WILL NOT BE PROCESSED WITHOUT THE FOLLOWING INFORMATION

REASON FOR BOOKING:  SURGERY  SPECIAL PROCEDURE

SURGEON: _____________________________________________________________________________________________
PATIENT DETAILS:
FULL NAME OF THE PATIENT: ________________________________________________________________________________________
ADDRESS: ___________________________________________________________________________________________________________
NATIONALITY: SEX: Male Female DOB: ( / / ) dd/mm/year
MOBILE NUMBER: _____________________________ RESIDENCE NUMBER: ________________________________________

BRIEF CLINICAL DETAILS

DIAGNOSIS: _________________________________________________________________________________________________
ALLERGY: __________________________________________________________________________________________________
CHRONIC DISEASES: No Diabetes MellitusAsthma Hypertension Hyperthyroidism CAD Osteoporosis
Hypothyroidism Rheumatoid Arthritis Others _________________________________________
ANY OTHER PATIENT’S SPECIAL DETAILS TO BE CONSIDERED: ______________________________________________________________

PAYMENT METHOD:
INSURANCE (Please Specify Name of Insurance Company) _______________________________________________________
(Please contact BEH Insurance Department for clarification and arrangement, Telephone numbers: 04-3454000 ext. 1026
or 2003. Fax number: 04-3453630)
SELF PAYING SURGEON’S ACCOUNT

PROCEDURE DETAILS:
PROCEDURE/SURGERY PLANNED: _____________________________________________________________________________
DATE OF SURGERY: _____________________________________ ANESTHESIA TYPE: ______________________________________________
ESTIMATED LENGTH OF SURGERY: __________________________ ESTIMATED LENGTH OF ADMISSION: __________________________
INVESTIGATION(S) TO BE DONE: ___________________________________________________________________________________________
SPECIAL EQUIPMENT / SUPPLY NEEDED: ___________________________________________________________________________________
ANY ORDERS PLEASE MENTION HERE: _____________________________________________________________________________________
________________________________________________________________________________________________________________________
SIGNATURE AND STAMP OF THE SURGEON AND/OR CLINIC
* Please attach patient’s valid ID copy or passport copy and valid
insurance card copy.

TO BE FILLED BY BEH STAFF

VERIFICATION OF PRIVILEGES
DOCTOR HAS APPROVED PRIVILEGES FOR THE SURGERY PLANNED/BOOKED.  Yes  No

VERIFIED BY: ___________________________________________ _________________________________________________

IPD NURSING SUPERVISOR SPECIALIST ANESTHETIST
O.T. CASE CONFIRMATION
SURGERY CONFIRMED DATE: ___________________________________ TIME: __________________________________________________
CONFIRMED BY: DATE: _________________________________________________
O.T. CASE CANCELLATION AND RESCHEDULE
REASON FOR CANCELLATION: ____________________________________________________________________________________________
________________________________________________________________________________________________________________________
CANCELLED BY: DATE: _________________________________________________
RESCHEDULE NEEDED: NO YES ~ TO DATE & TIME: _______________________________________________________________
CONFIRMED BY: DATE: _________________________________________________

Date of Last Revision: 08/04/2017 BEH-FM-63, Rev. 8