Private hospital Costa Rica, clinics, specialist doctors, medical services, surgeries by Clinica Biblica Costa Rica

PRE-ADMISSIONS FORM

The purpose of this online form is to streamline the steps leading up to surgery and hospitalization by giving our clients the option of sending the information necessary for starting the admissions process from the comfort of their home.

Date of admission to the Hospital:

Time:

First and Middle Names:

First Last Name:

Second Last Name:

Email:

Sex: ( M / F )

Age::

Civil Status:

Place of birth:

Date of Birth:

Nationality:

Identification number:

District:

County:

Province:

Physical address

Telephone:

P.O. Box:

Occupation:

Place of work:

Father’s Name:

*identification number:

Mother’s Name:

*identification number:

Spouse’s Name:

*identification number:

Name of treating physician:

Type of service/procedure:

Hospitalization required?:

If you plan on using medical insurance, or if payment is by special agreement or exchange, please indicate the name in the space provided

*Optional

Note:
If you have any questions regarding preparing or caring for your surgery, please call the following telephone number: 2522-1000 extensions 1101, 1102, or 2007.