PRE-ADMISIÓN | Patriotismo

HOSPITAL PRE-ADMISSION

Patriotism Unity

* This form only applies within 48 hours prior to entry.

Patient's data

Name

Date of birth

Religion

Last name

Mother's last name

Cell phone

Place of birth

Country

Condition

City

Nationality

Address

Country

City

Cologne

Condition

Municipality or Mayor's Office

Postal Code

Street and no.

Home Phone

Responsible for the Patient

Nombre del Responsable

Relación con el Paciente

Apellido Paterno

Correo electrónico

Apellido Materno

Teléfono del Responsable

Address of the Responsible

Calle y núm.

Cologne

City

Postal Code

Home phone

Procedimiento o tratatmiento al que se someterá el paciente:

Nombre del Médico Tratante

Teléfono del Médico

Probable Entry Date

Individual or Agreement / Insurer

What phone number do you want us to contact to follow up on your pre-admission, and at what time:

Teléfono de Contacto

En procedimientos quirúrgicos (incluyendo procedimientos de: Hemodinamia, Endoscopia y/o Hemodialisis) podemos realizarle la prueba rápida antígeno SARS-CoV2 de manera gratuita el día de su ingreso.

¡Por su seguridad y la de todos!

I accept privacy policies of issued data

HOSPITAL PRE-ADMISSION

Patriotism Unity

* This form only applies within 48 hours prior to entry.

Patient's data

Place of birth

Address

Responsible for the Patient

Address of the Responsible

What phone number do you want us to contact to follow up on your pre-admission, and at what time:

Notice of Privacy

Términos y condiciones

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