Jimma University Medical Center
.
Patient Medical Consumption Form
Dateof Admission _______Date of Discharge
Patient Name: _______________________
.
Patient Medical Consumption Form
Date of Admission ______Date of Discharge
Patient Name: __________________
Sex:___Age __MRN__________
Ward
cold opd
Sex:___ Age __MRN__________
Bed No. ____
Bed No. ___
Total Nursing pro. Cost ______ (ETB)
Other Procedure costs _________(ETB)
Other Procedure costs _______(ETB)
Send by _____________Sign _______
by
C.triage
Ward
Total Nursing pro. Cost _______ (ETB)
Received
Jimma University Medical Center
Send by Ewunetu.l
______________Sig
Sign _____
Received by _____________Sig
_____
________
Receipt No.______________Date__________
Receipt No._____________Date______
.
Jimma University Medical Center .
Patient Medical Consumption Form
Date of Admission _______Date of Discharge
Patient Name: _______________________
Sex:___Age __MRN__________
Ward
cold opd
Bed No. ____
Total Nursing pro. Cost _______ (ETB)
Other Procedure costs _________(ETB)
Send by ________________Sign _______
Received by ______________Sig ________
Jimma University Medical Center
Patient Medical Consumption Form
Date of Admission ______Date of Discharge
Patient Name: __________________
Sex:___ Age __MRN__________
Ward
C.triage
Bed No. ___
Total Nursing pro. Cost ______ (ETB)
Other Procedure costs _______(ETB)
Send by
Ewunetu.l
Sign _____
Received by _____________Sig _____
Receipt No.________________ Date______
Receipt No.______________Date__________
Jimma University Medical Center
Jimma University Medical Center
Patient Medical Consumption Form
Dateof Admission _______Date of Discharge __
Patient Medical Consumption Form
Date of Admission ______Date of Discharge ___
Patient Name: _______________________
Patient Name: __________________
Sex:___Age __MRN__________
Sex:___ Age __MRN__________
Ward
cold opd
Bed No. ____
Ward
C.triage
Bed No. ___
Total Nursing pro. Cost _______ (ETB)
Total Nursing pro. Cost ______ (ETB)
Other Procedure costs _________(ETB)
Other Procedure costs _______(ETB)
Send by ________________Sign _______
Send by Ewunetu.l
Received by ______________Sig ________
Received by _____________Sig _____
Receipt No.________________ Date______
Sign _____
Receipt No.______________Date__________