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Get El Camino Hospital Form 174C 2016-2021

RDS OR BRING THEM WITH YOU ON ADMISSION PRE-ADMISSION RECORD Patient Registration Department: Mountain View 650-940-7111 PATIENT INFORMATION Date To Enter Hospital Physician Maternity Primary Care Physician (PCP) Yes No Patient’s Legal Name (Last, First, Middle) Maiden Name: Due Date / / Approximate Date Last Treated Previous Name: Place of Birth Date of Birth Age Sex Patient’s Address (Street, City, State, Zip Code) Patient’s Employer Occupation Name of Person Responsibl.

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