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Making a Booking
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Making a Booking
Making a Booking
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Booking Form
PLEASE CONFIRM BED AVAILABILITY ON EXT 1604/1605 BEFORE COMPLETING THIS ADMISSION FORM.
Surname
*
Christian name
*
Date of Birth
*
DD
/
MM
/
YYYY
Address
*
Phone Number
Mobile Number
Email Address
Gender
*
>
Male
Female
Last Admission Date
DD
/
MM
/
YYYY
Readmission
>
Yes
No
Hospital Number
Consultant Name
*
GP's Name
Admission Date
DD
/
MM
/
YYYY
Day Case
>
Yes
No
Length of Stay
Admission Time
Accommodation
>
Private
Semi-Private
History of MRSA
>
Yes
No
Allergies/Alert to Allergies/Alerts/Special Needs
Please specify.
Medical Insurance
>
Self Payer
VHI
Quinn
Vivas
Garda
ESB
Prison Officer
NTPF
Other
Plan Type
>
D VHI Plan D
E VHI Plan E
VHI Plan B Options
VHI Plan C Options
VHI Plan D Options
VHI Plan E Options
C VHI Plan C
Plan B Excess
A VHI Plan A - (40% By Patient)
B VHI Plan B
VHI Plan A Options - (40% By Patient)
VHI First Plan Level 1
VHI First Plan Plus Level 1
VHI Family Plan
VHI Family Plan Plus
VHI Forward Plan
VHI Company Plan - (75.00 By Patient)
VHI Company Plan Plus - (75.00 By Patient)
Corporate Solutions
First Plan Select
Corporate - (125.00 By Patient)
VHI Company Plan Executive
VHI Company Plan Extra
VHI Company Plan Extra (Level 2)
Company Care Premium (No Excess)
Rapid Access Chest Pain Clinic
VHI First Plan Level 2
VHI First Plan Plus Level 2
VHI Company Plan Plus Level 2
VHI First Plan Select - (75.00 By Patient)
VHI Plan B Excess - (75.00 By Patient)
VHI Company Plan Plus Select
VHI Plan B Parents & Kids
VHI Plan B Options Parents & Kids
VHI Plan B Excess Parents & Kids - (75.00 By Patient)
VHI First Plan Extra - (125.00 By Patient)
BUPA Essential Plus (No Excess)
BUPA Essential
BUPA Essential Plus (Excess)
BUPA Health Manager
BUPA Gold
BUPA MRI Only
BUPA Pre 98 Essential Plan
BUPA Pre 98 Essential + Protection 1 Cash Plan
BUPA Pre 98 Essential + Protection 2 Cash Plan
BUPA Pre 98 Essential + Protection 1 Cash Plan
BUPA Pre 98 Essential + Gold Cash Plan
BUPA Health Manager 2nd Visit
BUPA Bone Density Only
BUPA Personal Care
BUPA Family Care
BUPA Company Care ( Excess)
BUPA Family Care 2nd Visit
BUPA Personal Care 2nd Visit
BUPA Company Care (No Excess)
BUPA Company Care Premium (Excess)
BUPA Company Health Plus (Excess)
BUPA Essential Gold
BUPA Health Manager Gold
BUPA Health Manager Silver
BUPA Company Health
BUPA Company Health Plus (No Excess)
BUPA Essential Starter
BUPA Company Care Premium (No Excess)
BUPA Rapid Access Chest Pain Clinic
BUPA Company Care Gold
BUPA Credit Union Family
VIVAS ME Level 1 - (40% By Patient)
VIVAS ME Level 2
VIVAS I/We Level 1 - (40% By Patient)
VIVAS I/We Level 2
VIVAS I/We Level 3
VIVAS I/We Level 4
VIVAS I/We Level 5
VIVAS Smart Level 2
VIVAS Market Level 2
VIVAS Nurses Plan
VIVAS Nurses Plan Plus
VIVAS Teachers Plan
VIVAS Teachers Plan Plus
VIVAS Celestica Level 2
VIVAS Hibernian Health Plan
VIVAS Hibernian Market Plan
VIVAS AA Health Plan
VIVAS AA Health Plan Plus
VIVAS Biz Plan - (75.00 By Patient)
VIVAS Biz Plan Plus - (75.00 By Patient)
VIVAS Total Life Level 1 - (40% By Patient)
VIVAS Total Life Level 2
VIVAS Total Life Level 3/4/5
VIVAS Plan 1001 - (75.00 By Patient)
VIVAS Plan 1002 - (100.00 By Patient)
VIVAS Rapid Access Chest Pain Clinic
VIVAS - Hibernian Business Plan Extra - (75.00 By Patient)
VIVAS Level 1 Hospital
VIVAS Level 1 Everyday
VIVAS Level 2 Hospital
VIVAS Level 2 Everyday
VIVAS I/We Level 2XS - (75.00 By Patient)
Garda - Rapid Access Chest Pain Clinic
ESB - Rapid Access Chest Pain Clinic
Prison Officers - Rapid Access Chest Pain Clinic
Self Paying Patients - Foreign Insurance
Self Paying Patients - Rapid Access Chest Pain Clinic
If other, please specify
Years Insured
Membership Number
Reason for Admission
Procedure and Code
Radiology Tests
Choose radiology tests
U/S Abdomen & Pelvis
U/S Carotids
U/S Guided Liver Biopsy
CT Abdomen & Pelvis
CT Brain
CT Thorax
Chest X-Ray
MRI Brain
CTPA
X-Ray Lumbar Spine
X-Ray Pelvis / Sacrum
X-Ray Cervical Spine
Barium Enema
Barium Follow - Through
Mammogram
Bone Density (DEXA)
Bone Scan
Carotid Doppler
Cardiology Tests
Choose cardiology tests
Echocardiogram
Holter Monitor
Telemetry
ECG
Stress ECG
ABPM
Bubble Study
Sleep Studies
Mod Bruce Stress
Erect & Supine BP
TOE
Pathology Tests
Choose pathology tests
Routine / Fasting Bloods
FBC, ESR
LFT's
TFT's
C - Reactive Protein
HBAIC
U & E
Ca++
PO4
Serum Ferritin
Serum Iron / TIBC / B12 / Folate
Auto Antibody Screen
Immunoglobulins
Haemochromatosis Test
Coeliac Antibodies
Hep A
Hep B
Hep C
24 HR Urinary Collection for VMA & Metanephrines
24 HR Urinary Collection 51HAA
Other
Other
Dietitian Review
Physiotherapy Review
Consultation / Clinical Nurse Specialist
Please specify.
Angiography
Angiography
Coronary Angiography
PCI
FFR
Cardioversion
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