Pre-admission form | Nimeh Shaaban Specialty Hospital

1 Patient details

First name*

Last name*

Father's name

Date of birth*

Gender*

MaleFemale

Marital status

SingleMarried

Nationality*

Country of residence*

City

Passport number*

Occupation

2 Medical information

Required specialty

Desired treatment or surgery*

Preferred doctor

Condition and medical history*Describe your symptoms, current diagnosis and any treatment you have had.

Current medications

Drug allergies

Previous surgeries and illnesses

Passport photo page * Choose or drop a filePDF, JPG, PNG — Max. 20 MB

Medical records (reports, test results, scans) * You can select several files at oncePDF, JPG, PNG, ZIP, DICOM

Other documents (optional) Choose file

3 Contact and travel

Companion details (optional)

Companion's name

Companion's relationship to the patient

Companion's passport number

Mobile phone

4 Review and submit

I confirm that the information I have provided is correct, and I allow the hospital's specialists to review my documents and contact me to assess my treatment. Medical information is kept confidential.