Name of Hospital__________________________________
Address_________________________________________
Telephone_______________________________________
Name of patient__________________________________
Age________________________-
Gender___________________________
Telephone_________________________________
Next of Kin Telephone contact_________________________________ (Give number of someone to be contacted incase of emergency)
Address_______________________________________
Date of visit____________________________________
Registration card Fee__________________________________
Consultation Fee______________________________________
Diagnostic Report_____________________________________
_____________________________________________ (Doctors observation and treatment recommendations and drug prescription)
Treatment Description __________________________
___________________________________________(describe treatment procedure as directed by doctor)
Treatment Procedure Fee________________________
Admission Fee per day_________________________________________ (Fill if applicable)
Admission Date___________________ Discharge Date_________________________ (Fill if applicable)
Days Admitted______________________________________________ (Fill if applicable)
Name of Drugs prescribed_____________________
Number of units______ Price per Unit______________ Total_________________________
Total Bill_________________________________
The above named patient has been treated and discharged on doctor’s approval.
Doctors Name________________________ Discharge Officer _______________
Date________________ Sign____________ Date ______________Sign_______