WIFI INTERNET ACCESS REQUEST FORM PATIENT NAME: ATTENDER NAME: ADMISSION DATE : FLOOR AND ROOM NO: PURPOSE OF USAGE For office use only REMARK’S IF ANY Patient Attender Signature: For office use only Approved By: Date: Name & Signature:
WIFI INTERNET ACCESS REQUEST FORM PATIENT NAME: ATTENDER NAME: ADMISSION DATE : FLOOR AND ROOM NO: PURPOSE OF USAGE For office use only REMARK’S IF ANY Patient Attender Signature: For office use only Approved By: Date: Name & Signature: