Admission - Saint George Hospital University Medical Center

Registration Details

Is your physicians an attending at SGH?

Yes No

Have you been referred to a specialist
at SGH by your physicians

Yes No

Physician Name

Select a Physician Name

If not referred kindly note the specialty required

Date of Admission*
Date of Procedure
Procedure Type

Patient Information

Please provide patient's name as it appears on legal documents.

First Name*
Father's Name*
Family Name*
Spouse Name
Date of birth*
City*
Country*
Phone*
E-mail*
Blood Group
Do you carry an Organ Donors Card?	Yes No
	If you wish to donate, visit NOODT website

Work Contacts

Are you an employee of SGHUMC

Yes No

Insert your hospital ID Card Number
Insert your Name as written in your hospital ID Card

Occupation
Employer
Employer's Phone
Ext
Employment Status

Parent, Legal Guardian

Relation to Patient*
First Name*
Middle Name*
Last Name*
Date Of Birth*
Address*
City
Country
Phone*
Additional Phone

Miscellaneous

Have you ever been a patient at Saint George Hospital

Yes No

Since this is your first Medical visit, ask for your personalized SGH ID card the day of your visit.

Third Party Coverage

Please mention if you are a self-payer or select your type(s) of insurance and complete the appropriate sections below

Self-Payer Insurance

Semi Private Private Luxe

Self Payer

Insurance Type

Private Insurance Public Insurance Both

Private Insurance Company*

Public Insurance Type

الصندوق الوطني للضمان الإجتماعي
رقم المضمون
إسم المضمون

الجيش
الرقم العسكري
إسم العسكري
الرتبة

الأمن العام
الرقم العسكري
إسم العسكري
الرتبة

تعاونية موظفين الدولة
رقم الإنتساب
إسم المنتسب
الوظيفة

قوة الأمن الداخلي
إسم المنتسب
الرتبة
رقم الكنية

قوة الأمن الداخلي - الجمارك
إسم المنتسب
الرتبة
رقم الكنية

Kindly note that you need to present the coverage approval the day of visit.

Other

Additional Comments/
Special Request

The Required Documents to upload are

Your ID(Lebanese Identity Card or Passport/ recto verso)
SGHUMC ID (if applicable)

Your Insurance Card (recto verso)

Admitting Request Form Number H.S.G. 024 (click to see the picture of the form) filled by your physician
Consent Form signed by your physician H.S.G 270/A (click to see the picture of the form)
Insurance Claim Form filled by the physician

Surgery Request Form filled by your physician (HSG 112)

Forms filled by your physician: Medical report(HSG 111)

Forms filled by your physician: Medical Prescription (HSG 114) and (HSG 299)

Admitting Request form filled by SGHUMC physician
Forms Filled by SGHUMC Physician
Insurance Claim Form filled by SGHUMC physician

If you have any questions or problems related to this form, please call (961) 1-441 122, Monday through Friday, between the hours of 9:00 a.m. and 4:00 p.m.

Website by

Admission Form

Registration Details

Patient Information

Work Contacts

Parent, Legal Guardian

Miscellaneous

Third Party Coverage

Other

The Required Documents to upload are

Admission Form

Registration Details

Patient Information

Work Contacts

Parent, Legal Guardian

Miscellaneous

Third Party Coverage

Other

The Required Documents to upload are

Support SGHUMC:

SGHUMC has sustained severe damages from the recent explosion in Beirut.