Hospital Combined Multi-Step Form

Advanced Neuro-Psychiatry Institute

A Hospital Unit of Behala Navajivan Welfare Society

Vill: Kalua, P.O: Joka, Kolkata - 700 104 | Mob: 9674172916

Admission, Declaration & Bond (Combined)

Patient Admission Details

Patient's Identification No.

Date of Admission

Time

Name of Patient (in Block Letters)

Occupation of Patient

Father’s / Husband’s Name

Address

P.O

P.S

Kolkata/District

Office Address

Age

Sex

Marital Status

Religion

Nationality

Relation of Patient to Guardian

Doctor Name (Under Treatment)

If complication arises, send back to home (Address & Phone No.)

The authority will take care and safety of the patient but cannot be held responsible for any accident. Valuables, ornaments, and money must be handled by the guardian. No money should be given to the patient.

I give consent for treatment including Anaesthesia, Electro Convulsive Therapy or any required treatment.

<>Signature of Guardian

<>Signature of Doctor / Authority

Patient / relative’s declaration regarding past medical ailments

Patient’s Name :

Age :

Sex :

Regn. No. :

Consultant :

Ailment	Yes / No	Duration
Hypertension (High Blood Pressure)	Yes No
Diabetes Mellitus	Yes No
Heart Disease	Yes No
Previous MI (Heart Attack)	Yes No
Previous Stroke	Yes No
Previous Surgery	Yes No
Thyroid Disease	Yes No
Smoker	Yes No
Alcohol Intake	Yes No
Tuberculosis	Yes No
Bronchial Asthma	Yes No
C.O.P.D.	Yes No
HIV / STD	Yes No
Osteo-arthritis	Yes No
Cancer	Yes No
Kidney Disease	Yes No
Pressure Sore (Bed Sore)	Yes No
Allergy (Medicine / Others)	Yes No
Other Ailments	Yes No

Patient / relative’s declaration regarding past medical ailments

Patient’s Name :

Age :

Sex :

Indoor Regn. No. :

Consultant :

I, Sri / Smt :

S/D/W/H/o :

giving consent for:

Description	Yes / No
1) Relevant Investigations & Treatment	Yes No
2) Emergency treatment in physical health deterioration	Yes No
3) Transfer of patient in emergency (which will be paid by me immediately)	Yes No

Full Signature of Patient’s Relative :

Date

Time

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Declaration & Undertaking Bond for Admission

Name of Patient

Age

Date of Birth

Sex

Permanent Address

Aadhaar / ID No. (if any)

Guardian / Nominated Representative (NR) Details

Full Name

Relationship with the Patient

Legal Guardian / Nominated Representative (tick one)

Legal Guardian

Nominated Representative

ID Proof (Aadhaar / Passport / Voter ID)

Contact Number

Address

Declaration and Undertaking

I, the undersigned, hereby confirm the following:

I am admitting the above-named patient to Advanced Neuropsychiatry Institute, Joka under the Mental Healthcare Act, 2017. I understand my responsibilities as the Legal Guardian or Nominated Representative.
I agree that once the doctors declare the patient is ready for discharge, I will take the patient home within seven (7) days of being informed.
I understand that if I do not arrange discharge on time or do not pay the monthly or agreed charges, it may be seen as neglect or abandonment. In that case, the hospital may:
- Notify the Mental Health Review Board or local authorities under Section 105 of the Mental Healthcare Act, 2017.
- With help from authorities, safely escort the patient to their home or arrange other proper aftercare.
I agree to pay all charges on time. If I fail to pay, the hospital may take legal steps to recover the amount or stop non-emergency services after informing me.
I confirm that I have read and understood the hospital rules and the rights and duties of patients and guardians under the Mental Healthcare Act.

<>Signature of Guardian / NR

Date:

<>Signature of Hospital Representative

Date:

Submit & Finish

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Advanced Neuro-Psychiatry Institute

Admission, Declaration & Bond (Combined)

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