Hospital Admission Form

Purpose: This form is used to document essential patient information during the hospital admission process for inpatient care. It captures identification, contact, insurance, medical and emergency details to ensure appropriate care and incident handling.

Patient Information

First Name: {firstName}

Last Name: {lastName}

Date of Birth: {dob}

Gender: {gender}

Contact Number: {contactNumber}

Email Address: {email}

Home Address: {address}

Emergency Contact

Emergency Contact Name: {emergencyName}

Relationship: {emergencyRelationship}

Phone Number: {emergencyPhone}

Insurance Information

{#hasInsurance}

• Insurance Provider: {insuranceProvider}
• Policy Number: {policyNumber}
• Policy Holder Name: {policyHolderName}

{/hasInsurance}

{^hasInsurance}The patient does not have valid insurance coverage on file.{/hasInsurance}

Medical Information

Primary Physician: {physicianName}

Known Allergies: {allergies}

Current Medications: {medications}

Reason for Admission: {admissionReason}

Medical History (List)

{#medicalHistory}

• {condition}

{/medicalHistory}

Admission Details

Admission Date: {admissionDate}

Admitting Department: {department}

Room/Ward: {room}

Consulting Doctor: {consultingDoctor}

Additional Notes

{notes}

Accompanying Family Members