Impilo Patient Information Form
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1
2Impilo Patient information form
In case of a pre-admission please fax or hand in at pre-admissions ASAP - fax ________________________________
Should you have any queries please contact reception for assistance on telephone ____________________________
HOSPITAL USE ONLY
DOCTOR:
SURGERY BOOKED TIME:
TIME OF ARRIVAL:
WARD DETAILS:
BED DETAILS:
PRE-ADMISSION NUMBER:
PATIENT INFORMATION
PATIENT’S PERSONAL INFORMATION
ID NUMBER /PASSPORT NUMBER /PATIENT LIFE NUMBER
IDENTIFIER NUMBER:
IDENTIFIER TYPE:
SURNAME:
NAME:
INITIALS:
OTHER NAMES:
KNOWN AS:
DR /FR /MISS /MR /MRS /MS /PROF /REV
MALE / FEMALE
DATE OF BIRTH :
TITLE :
GENDER:
( 000 ) 000 - 0000
WORK NUMBER:
HOME NUMBER:
MOBILE NUMBER:
MOBILE / WORK / HOME / EMAIL
Y / N
Y / N
PREFERRED METHOD OF CONTACT?
RECEIVE MARKETING?
RECEIVE STATEMENTS?
EMAIL ADDRESS:
RESIDENTIAL ADDRESS:
POSTAL ADDRESS:
SUBURB:
SUBURB:
CITY
CODE:
CITY
CODE:
SINGLE /MARRIED /DIVORCED
FRUITARIAN / HALAAL / KOSHER / NONE / VEGAN / VEGETARIAN
MARITAL STATUS:
DIETARY PREFERENCE :
RELIGION:
CONGREGATION
MINISTER
EMERGENCY CONTACT
(PERSON TO BE CONTACTED IN CASE OF A MEDICAL EMERGENCY)
SURNAME:
NAME:
CHILD / FRIEND / PARENT / GUARDIAN / RELATIVE / SIBLING / SPOUSE
RELATIONSHIP TO PATIENT:
MOBILE NUMBER:
EMERGENCY CONTACT’S ADDRESS:
WORK NUMBER:
SUBURB:
HOME NUMBER:
CITY:
CODE:
ALTERNATIVE CONTACT:
(PERSON NOT LIVING AT THE SAME ADDRESS)
SURNAME:
NAME:
CHILD / FRIEND / PARENT / GUARDIAN / RELATIVE / SIBLING / SPOUSE
RELATIONSHIP TO PATIENT:
MOBILE NUMBER:
ALTERNATIVE’S CONTACT’S ADDRESS:
WORK NUMBER:
SUBURB:
HOME
NUMBER:
CITY:
CODE:
PTO…/PAGE 2 CONTINUED
PSM-FORM-ADM/001.5
Revision 0 – May 2009
Page 1 of 2
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Parent category: Medical