Patient Registration

Once you have booked your appointment, please complete this form and submit it to register as a patient at Omid Hospital.

(Mandatory field)

First Name(s)

Last Name

Date of Birth

Gender

Country of Residence

Nationality

Ethnic Group

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

Postal Code

Home Telephone Number

Mobile Telephone Number

Email Address

Overseas Address (if applicable)

Overseas Post Code

Overseas Home Telephone Number

CLINICAL DETAILS

GP Name (General Practitioner)

GP Address

Consultant Name

Preferred Appointment Date(s)

Preferred Consultant

Preferred Specialty

FINANCIAL DETAILS

Description of Symptoms

Payor / Purchaser Name

Membership / Reference Number

Insurance Pre-Authorisation / Claim Number

PAYMENT UNDERTAKING

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.

DATA PROTECTION NOTICE

For further information please refer to the Data Protection and Your Information leaflet.

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)
By accepting, you agree to Omid Hospital’s Privacy Policy. You also agree that this data will be shared in line with the Iran General Data Protection Regulation.

Please send all youre medical records as an intgrated pdf file

Upload file (max:6MB , Formats: pdf )

By accepting, you agree to Omid Hospital’s Privacy Policy. You also agree that this data will be shared in line with the Iran General Data Protection Regulation.

I Agree

Patient Registration

PAYMENT UNDERTAKING

DATA PROTECTION NOTICE

For further information please refer to the Data Protection and Your Information leaflet.

Our Links

Other Links

Contact Us