PATIENT INFORMATION FORM (for new patients) A) GENERAL INFORMATION
Patient’s name in full: (no initials please)
Year of Birth :
: 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
Village / Town
Taluk & District
State & Country
If you are referred to another department for opinion/ treatment, the option is available to you to be seen either
as a General
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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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
To obtain a
Do not register for a new card as time consuming for you and us.
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.
producing the payment registration, the MRO
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.
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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