Once you have booked your appointment, please complete this form and submit it to register as a patient at Omid Hospital.
Country of residence
Specify other ethnic group
If an interpreter is required, please state which language is to be interpreted
Next of kin name, address and telephone number
Relationship to next of kin
Iran address of patient
Home telephone number
Mobile telephone number
Overseas address (if applicable)
Overseas post code
Overseas home telephone number
Preferred appointment date(s)
Description of symptoms
Payor / purchaser name
Membership / reference number
Insurance Pre-authorisation / claim number
Sponsored letter of guarantee
All patients / patient payor / representative
In consideration of the hospital accepting me/the patient for nursing care and accommodation, I/we undertake to pay all services rendered and items supplied to me/the patient in accordance with the hospital's charges applicable at the time of treatment, including all personal expenses, such as telephone calls, take home medication, supplies and catering for relatives etc. I acknowledge that I remain liable for such payment, whether or not I/ the patient have/has medical insurance or third party sponsorship in respect of some or all of the services provided and items supplied. If following discharge there is a shortfall or excess due to the Hospital, I accept that I/the patient will be invoiced for this sum and I hereby agree to pay this direct to the Hospital.
I acknowledge that the consultant / specialist is not an employee or agent of the hospital and that, unless otherwise stated, he/she will invoice me/the patient separately for their services, which I am responsible to pay to him/her directly.
Medical information will be kept confidential. It will only be disclosed to those involved with the provision of your treatment or care, or to their agents, and, if applicable, to any person or organization who may be responsible for meeting your treatment expenses, or their agents.
Omid Hospital is committed to continuous improvement. Your medical care information may be used for audit and quality monitoring, some of which will be independently audited. Where it is not possible to use anonymised information, personal identifiable information may be used for essential purposes and will comply with the Data Protection Act
Name of person submitting this information (if different from the patient)
Address (if not already indicated)
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Farhangian Blv,Bahonar Blv,Urmia,Iran
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