Direct Admission

[textarea columns=80 rows=25 default="Referring Physician: ***
Summary of clinical history and reason for admission: ***
Admitting diagnosis: ***
Plan of care: ***
Type of admission: ***Emergency/Urgent/Routine***
Room assignment needs: ***ICU/Private/Strict Isolation/Airbourne Isolation/Monitored bed***
IV drips or other needs: ***
Mode of transportation: ***Private car/Ground ambulance/Fixed wing***
Insurance Information: ***Unknown/Medicare/Private Insurance ---/Medical Assistance ---/Managed Care ---***"]