Pre-admission Form - Wolper Jewish Hospital

Welcome!

We appreciate your choice of Wolper Jewish Hospital.

Our aim is to ensure quality care with individual attention and a comfortable atmosphere. Please feel free to discuss your feeling with our staff and do not hesitate to ask any questions you may have.

Your doctor will book your stay with the hospital and inform you of the date of the admission. Your doctor will also explain your operation or treatment and will complete a consent form with you.

Pre-admission is an Important Step

It allows us to prepare for your stay and provide you with the best of care.

The Wolper Jewish Hospital will also endeavour to provide you with an estimation of fees for your hospitalisation prior to admission.

To avoid lengthy delays on admission and to complete the necessary financial arrangements, we request that you complete the form below at least 3 days prior to your admission date or, if you prefer, we can send you a paper form to complete and return to us. By completing the on-line form below, we can make sure you admission is completed as quickly and easily as possible.

For late bookings or enquiries please phone the Admissions Officer on (02) 9328 6077.

Privacy and Security

Wolper Jewish Hospital acknowledges our obligations to you under the Privacy Act (as amended). Personal information we collect will be used primarily to ensure that you receive optimal care but may be used for other related purposes. For more details on the use of your personal information please review the Wolper Commitment to Patient Privacy Statement. Please note that unless marked with an asterix (*), all data items are required either by legislation or for billing purposes. Those items marked with an asterix (*) are not mandatory however we do recommend that these fields be completed. For more information on the purpose of these data elements please consult the Wolper Commitment to Patient Privacy Statement.

Personal Details

Surname:

Previous names:

Given names:

Title:

Mr Mrs Miss Ms
Mst Dr Rev Other:

Sex:

Male Female

Date of birth:

Age:

Address:

Postcode:

Postal Address:
(if different)

Postcode:
(if postal address different)

Phone Private:

Phone Business:

Phone Mobile:

Country of birth:

Marital status:

Married Single Widowed
Divorced Separated Defacto

Main language spoken at home:

* Occupation:

Aborigine:

Yes No

Torres Strait islander:

Yes No

* Religion:

Treatment Details

Date of Admission:

Reason for Admission:

Date of Operation:
(if for surgery)

Length of Stay:

days

Item numbers:
(see doctors referral)

Hospital Insurance

Do you have
Hospital Insurance:

Yes No If yes, please complete this section:

Name of fund:

Membership no:

Is there excess on your table:

Yes No Amount $

Next of kin *

Name in full:

Address:

Postcode:

Phone Private:

Phone Business:

Phone Mobile:

Relationship:

Pharmacy *
This information is required so that the proper concessions can be made. If this information is not provided at time of dispensing patients will be charged the full amount which can not be amended.

Do you have any concession, pension or safety net cards for pharmacy prescriptions:

Yes No

Card Number:
(if yes)

Medicare Card
If all Medicare details are not provided, all pharmacy will be charged at full rate, which can not be amended.

Card Number:

Patient Reference No:
(to left of your first name)

Card Expiry Date:

Overnight Patients - please nominate preferred accommodation
While no guarantee can be given, every effort will be made to accommodate patients as requested:

Private Room Shared Ward (2 - 3 beds)

Other Details

Reason for admission:

Treating doctor:

Referring doctor:

Is your admission necessary because of an accident:

Yes No

If yes, cause of injury:

Place of injury:

Date you were last admitted to hospital:

Hospital:

Have you been a patient in this hospital before:

Yes No

Year:

Workers Compensation/Third Party
A letter from your insurer accepting liability must be provided or full payment will be required on admission.

Date of accident:

Employer:

Address:

Phone:

Insurance company:

Address:

Phone:

Contact Name:

Claim No:
(compulsory)

Payment of Account

Wolper Jewish Hospital will forward accounts to insurers on your behalf asking only that you provide all insurance details prior to admission, or as soon as possible after admission for emergency patients.

Any fees not covered by insurance are payable on admission, and any other fees raised during the period of hospitalisation are payable on discharge.

Patients must understand and agree to pay all hospital accounts, in the event that my fund or insurance claim should be declined for any reason.

I do not wish to receive promotional material from the Wolper Jewish Hospital.

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