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PATIENT INFORMATION FORM (for new patients) A) GENERAL INFORMATION

Patient’s name in full: (no initials please)

Year of Birth :

Sex Religion

: Male / Female : Marital status : Married / Unmarried / Child

Occupation Has the patient ever visited CMC for treatment before? Yes/No Name of father or husband (in full) Designation (Occupation) : :

B) APPOINTMENT INFORMATION Department(s) to be consulted : Preferred date of first appointment (morning) : Payment details: Amount, date, bank :

C) PERMANENT ADDRESS

House No.

:

Street

:

Village / Town

:

Post Office

:

Taluk & District

:

Pin Code

:

State & Country

:

REFERRALS

If you are referred to another department for opinion/ treatment, the option is available to you to be seen either

as a General

or

Private

patient.

If you choose to

a General patient and the clinic you are referred the same day, contact the MRO of that clinic appointment.

to is for

be on an

However, if the clinic you are referred to is on another day, you have to pay Rs.50/- for a General patient at

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21

payment counters showing the referral slip. If you do not

show the referral slip previous clinic.

your chart will be sent to your

To see a consultant get an appointment by making a payment of Rs.450/- at the cash counter in the ISSCC, ground floor.

SAFETY OF YOUR REGISTRATION CARD

The registration card issued to you is an important

document. Please duplicate registration

retain

number

it carefully.

To obtain a

card

contact

G-31/G-32

(Supervisor

counter)

in

the

ground

floor

of

OPD

building.

Do not register for a new card as time consuming for you and us.

this

is

expensive

and

OUT-PATIENT CLINICS

On reaching the appropriate out-patient clinic, submit the appointment slip to the MRO, please be seated

in the clinic,

waiting hall. When your medical chart reaches the MRO in the hall will call your name.

the On

producing the payment registration, the MRO

slip

which you

had obtained

will

send your

chart to one

during of the

doctors. If you chart will go to Your name will

have registered as a Private patient, your a consultant or his/her approved assistant. be called out when your turn comes and

you will to your

be seen by the reporting time.

doctor.

Report

to

MRO

according

When you meet with your doctor feel free to discuss all your health problems with him/her, giving all relevant information about your sickness and follow the advice given.

If the doctor decides to have some clinical tests done, such as examination of blood, urine, stool etc., you will be issued the required forms. The steps to be followed are described below under the heading “Tests and Investigations”.

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