International Patient Department Admission Form

Please complete and return admission form and patient history to Ebne-Sina hospital.




Reason for this admission and history or preseating illness.

Medical Surgical History: List the medical condition / operations performed and date


Current Medications:

Please list all medications including complementary medications and bring these to hospital in their original containers.

fill by this format: Drug Name - Dose - Frequency / Time

Contact Us

Address : Ayatallah Kashani Blv, Sadeqieh Sq, Tehran, Iran

Telephone :+98 21 47900

Fax :+98 21 44070784

Postal code : 1481798113

E-Mail : info@Ebnesinahospital.com