[HospitalName] [Address]

Patient No	:	[PatientNo]	Name	:	[Name]
Gender/ Age	:	[GenderAge]	[Ward]	[:]	[WardName] [MLC]   [Insured]
[IP #]	[:]	[IpNo]	[Bed #]	[:]	[BedNo]
Dept./Unit	:	[Dept]	Patient Type	:	[PatientType]