Consultation Form printable pdf download

Consultation Form

CONSULTATION FORM

Dear Doctor, you are kindly requested to complete this Consultation Form and fax it to NAS Claims Centre at 02-

6766227. For prescriptions, kindly use Prescription/Advice Form

PATIENT INFORMATION

FAMILY NAME _________________________

GIVEN NAME _____________________________

DATE OF BIRTH _____________________________

GENDER _________________________________

CARD NBR: ______________________________

PAYER ___________________________________

CASE INFORMATION ACUTE

CHRONIC

PRE-EXISTING

INJURY

DIAGNOSIS

_____________________________________________________________________________

AETIOLOGY _____________________________________________________________________________

( Please indicate the exact cause in case of injuries and maternity-related cases)

SYMPTOMS:

CLINICAL FINDINGS:

REMARKS

TREATING PHYSICIAN _________________________________________

HOSPITAL /CLINIC _____________________________________________

CONSULTATION DETAILS

NEW

FOLLOW-UP

CONSULTATION FEES ________

DOCTOR’S SIGNATURE AND STAMP _____________________________ DATE _____________________

I hereby allow NAS authorized personnel to obtain any requisite medical details from my current and previous

physicians and case files.

BENEFICIARYS’ SIGNATURE ____________________________________________

NAS Administration Services , P.O Box 44505 Abu Dhabi , UAE

Tel : 02-6777997

Fax : 02- 6766227

Consultation Form