Name: Kristine N.

Olitin
Year & Block: BSN1-B
Group: 6
Patient Admission Form
ADMISSION DETAILS
Admitting doctor: Dr. Clyden Jaile Ramirez Admission date: 4/15/2022
Planned procedure: Monitoring Hct and CBC Item number(s): N/A
PATIENT DETAILS
Is the person completing the form the patient? Yes  No 
If No, Your Name: Your phone No:
Is the patient under the age of 18 years? Yes  No 
If Yes; what is the name of the legal guardian?
Given name: Zchanishka Gayle Family name: Llenaresas
Preferred Name: Shane
Residential Address: Purok 1 San Rafael Province: Albay
City: Guinobatan Post Code: 4503
Telephone: Home: N/A Work: N/A Mobile: 09456728392
If there is a message service, may we leave a message? Yes No Can we send SMS? Yes No
eMail Address: zchanishkagayle_15@gmail.com
Your email address is important as it is used to confirm that your admission form has been received.
Date of birth: 12/15/2000 Gender: Male  Female  Indeterminate 
Marital status: Defacto  Divorced  Married  Separated  Single  Widowed 
Employment: Unemployed  Retired  Employed  Occupation: N/A

CONTACT PREFERENCES
Indicate your preferred method of contact; Home phone  Mobile  eMail  SMS  Post 
NEXT OF KIN

Patient Admission Form

Family name: Llenaresas Given name: Weng Relationship: Mother
Address: Purok 1 San Rafael
City: Guinobatan Province: Albay Post Code: 4503
Telephone: Home: N/A Work/Day: Housewife Mobile:09367289176
PERSON TO NOTIFY ON DISCHARGE
Family name: Llenaresas Given name: Weng Relationship: Mother
Address: Purok 1 San Rafael
City: Guinobatan Province: Albay Post Code: 4503
Telephone: Home: N/A Work/Day: Housewife Mobile:09367289176
ENDURING POWER OF ATTORNEY
Do you have a current Advance Health Directive? Yes  No 
If Yes; please provide a copy to the hospital.
Do you have a current Enduring Power of Attorney – Health and Medical Guardian? Yes  No 
Name: Relationship: Telephone: