Admitting Record for Health Care Facilities Form

This 4-part carbon interleaved snap set contains information related to admission, financial responsibility, information release authorization and discharge. Part 3 serves as a notification slip, Part 4 is an admitting file card.

Part 1 (white paper) and Part 2 (yellow paper) measure 8 1/2" x 11: detached, Part 3 (pink paper) and Part 4 (heavy white ledger, stock) measure 8 1/2" x 4 1/4" if needed for filing. All parts printed in black ink, packaged in 100s.