Date

Clinic Name

Emirates

Card Holder’s Name:

SEX

Card Holder’s Tel No

Mobile No

Affix copy of front side of Insurance card

Ins. Card

Valid up to

Company Name

Employee No

Nationality

Clinical Details:

Temp

o c

B.P.

MmHg

Pulse.

/ Min

Sign & Symptoms

Date of onset of illness:

Emergency

Work related

new visit

Follow up visit

Diagnosis

Management plan (Services inside the clinic including injections and investigations)

Doctor’s Name and signature with seal:

Diagnostic Procedures referred outside:

I hereby authorize the physician, Hospital or pharmacy to file a claim for medical services on my behalf and I confirm that the abovementioned examination/Investigation/therapy is given to me by the doctor. I hereby authorize any Clinic, Physician, Pharmacy or any other person who has provided medical services to me to furnish any and all information with regard to any medical history, medical condition, or medical services and copies of all medical and Clinic records.

Date

Signature of the Patient

Pharmaceuticals (to be filled by treating doctor only)

CLINIC

PHARMACY

DIAGNOSTIC CENTRE

HOSPITAL OR OTHER