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Inpatient Booking Form

To be completed by medical professionals only.

Booking Form

Patient Details

Admission Details

Payment Details

PRICE CONFIRMED WITH BOOKINGS TEAM:


EXTRA REQUIRMENTS

C-ARM/X-RAY/IMAGE-INTENSIFIER NEEDED:

Micro Air Handpiece requirement*:YESNO

Haemaglobin on admission:YESNO

Group and save required:YESNO

If patient is anticoagulated do you need it reversed for surgery:YESNO

Have you attached details of patients past medical and medication history?*:YESNO

Upload any patient supporting documents

FOR OFFICE USE:

Completed By:

* It is mandatory to supply this information prior to admission