{"id":6145,"date":"2024-07-26T09:46:52","date_gmt":"2024-07-26T07:46:52","guid":{"rendered":"https:\/\/www.serveisclinics.com\/make-a-clinic-admission\/"},"modified":"2026-09-20T19:37:17","modified_gmt":"2026-09-20T17:37:17","slug":"make-a-clinic-admission","status":"publish","type":"page","link":"https:\/\/www.serveisclinics.com\/en\/make-a-clinic-admission\/","title":{"rendered":"Clinic Admission"},"content":{"rendered":"\t\t<div data-elementor-type=\"wp-page\" data-elementor-id=\"6145\" class=\"elementor elementor-6145 elementor-1878\" data-elementor-post-type=\"page\">\n\t\t\t\t<div class=\"elementor-element elementor-element-5399bfb e-flex e-con-boxed e-con e-child\" data-id=\"5399bfb\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-b23dc6f elementor-widget elementor-widget-heading\" data-id=\"b23dc6f\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h1 class=\"elementor-heading-title elementor-size-default\">Patient admission<\/h1>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-feaf533 e-flex e-con-boxed e-con e-parent\" data-id=\"feaf533\" data-element_type=\"container\" data-e-type=\"container\" data-settings=\"{&quot;background_background&quot;:&quot;classic&quot;}\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-fd0dbdc bold elementor-widget elementor-widget-heading\" data-id=\"fd0dbdc\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"heading.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t<h2 class=\"elementor-heading-title elementor-size-default\">Clinic Admission Form<\/h2>\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t<div class=\"elementor-element elementor-element-36e7b47 e-flex e-con-boxed e-con e-parent\" data-id=\"36e7b47\" data-element_type=\"container\" data-e-type=\"container\">\n\t\t\t\t\t<div class=\"e-con-inner\">\n\t\t\t\t<div class=\"elementor-element elementor-element-d649906 elementor-widget elementor-widget-shortcode\" data-id=\"d649906\" data-element_type=\"widget\" data-e-type=\"widget\" data-widget_type=\"shortcode.default\">\n\t\t\t\t<div class=\"elementor-widget-container\">\n\t\t\t\t\t\t\t<div class=\"elementor-shortcode\">\n<div class=\"wpcf7 no-js\" id=\"wpcf7-f7006-o1\" lang=\"en-US\" dir=\"ltr\" data-wpcf7-id=\"7006\">\n<div class=\"screen-reader-response\"><p role=\"status\" aria-live=\"polite\" aria-atomic=\"true\"><\/p> <ul><\/ul><\/div>\n<form action=\"\/en\/wp-json\/wp\/v2\/pages\/6145#wpcf7-f7006-o1\" method=\"post\" class=\"wpcf7-form init\" aria-label=\"Contact form\" enctype=\"multipart\/form-data\" novalidate=\"novalidate\" data-status=\"init\">\n<fieldset class=\"hidden-fields-container\"><input type=\"hidden\" name=\"_wpcf7\" value=\"7006\" \/><input type=\"hidden\" name=\"_wpcf7_version\" value=\"6.1.7\" \/><input type=\"hidden\" name=\"_wpcf7_locale\" value=\"en_US\" \/><input type=\"hidden\" name=\"_wpcf7_unit_tag\" value=\"wpcf7-f7006-o1\" \/><input type=\"hidden\" name=\"_wpcf7_container_post\" value=\"0\" \/><input type=\"hidden\" name=\"_wpcf7_posted_data_hash\" value=\"\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_group_fields\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_hidden_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_visible_groups\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_repeaters\" value=\"[]\" \/><input type=\"hidden\" name=\"_wpcf7cf_steps\" value=\"{}\" \/><input type=\"hidden\" name=\"_wpcf7cf_options\" value=\"{&quot;form_id&quot;:7006,&quot;conditions&quot;:[{&quot;then_field&quot;:&quot;group-dadesMetge&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mostrar-dades-metge&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;1&quot;}]},{&quot;then_field&quot;:&quot;conditional-group-factors-risc&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;factors-risc&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Others&quot;}]},{&quot;then_field&quot;:&quot;conditional-group-resistencies&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;resistencies&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;Yes&quot;}]},{&quot;then_field&quot;:&quot;group-info-adicional&quot;,&quot;and_rules&quot;:[{&quot;if_field&quot;:&quot;mostrar-camps-opcionals&quot;,&quot;operator&quot;:&quot;equals&quot;,&quot;if_value&quot;:&quot;1&quot;}]}],&quot;settings&quot;:{&quot;animation&quot;:&quot;yes&quot;,&quot;animation_intime&quot;:200,&quot;animation_outtime&quot;:200,&quot;conditions_ui&quot;:&quot;normal&quot;,&quot;notice_dismissed&quot;:false,&quot;repeater_remove_button&quot;:&quot;bottom&quot;,&quot;notice_dismissed_rollback-cf7-5.9.7&quot;:true}}\" \/><input type=\"hidden\" name=\"_uacf7_hidden_conditional_fields\" value=\"\" \/>\n<\/fieldset>\n\t\t\t\t<style>\n\t\t\t\t\t.uacf7-uacf7style-7006 label {\n\t\t\t\t\t\tcolor: #292929;background-color: #ffffff;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: 500;margin-top: 20px;margin-bottom: 15px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"email\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"number\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"password\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"search\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"tel\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"text\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"url\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"date\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"radio\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"checkbox\"],\n\t\t\t\t\t.uacf7-uacf7style-7006 select,\n\t\t\t\t\t.uacf7-uacf7style-7006 textarea {\n\t\t\t\t\t\tcolor: #000000;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: 500;border-width: 1px !important;border-color: #1e73be !important;border-style: solid!important;border-radius: 5px;margin-top: 20px;margin-bottom: 15px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7006 .wpcf7-radio span,\n\t\t\t\t\t.uacf7-uacf7style-7006 .wpcf7-checkbox span {\n\t\t\t\t\t\tcolor: #000000;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: 500;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7006 textarea {\n\t\t\t\t\t\theight: 100px;\t\t\t\t\t}\n\n\t\t\t\t\t.wpcf7-form-control-wrap select {\n\t\t\t\t\t\twidth: 100%;\n\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"submit\"] {\n\t\t\t\t\t\tcolor: #ffffff;background-color: #1e73be;font-size: 16px;font-family: Ruda;font-style: normal;font-weight: normal;border-width: 1px;border-color: #1e73be;border-style: solid;border-radius: 5px;margin-top: 20px;margin-bottom: 15px;\t\t\t\t\t}\n\n\t\t\t\t\t.uacf7-uacf7style-7006 input[type=\"submit\"]:hover {\n\t\t\t\t\t\tcolor: #000000;background-color: #ffffff;border-color: #1e73be;\t\t\t\t\t}\n\n\t\t\t\t\t\t\t\t\t<\/style>\n\n\t\t\t\t<div class=\"uacf7-uacf7style uacf7-uacf7style-7006\"><div class=\"uacf7-form-wrapper-container uacf7-form-7006  uacf7-uacf7style uacf7-uacf7style-7006\"><label style=\"font-size: 20px;font-weight: 600\">Requester details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Admission request date*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-solicitud-ingres\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-solicitud-ingres\" \/><\/span><\/label> \n\n<label> Contact phone number of the person requesting admission*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-solicitant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefon-solicitant\" \/><\/span> <\/label>\n<\/div>\n\n\n<div class=\"uacf7-col-4\"> \n<label> Referring hospital or center*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"centre-referencia\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"centre-referencia\" \/><\/span> <\/label>\n\n<label> Email address of the person requesting admission*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"correu-solicitant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"correu-solicitant\" \/><\/span> <\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\"> \n<label> Person requesting admission*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"nom-solicitant\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom-solicitant\" \/><\/span> <\/label>\n<\/div>\n<\/div>\n\n\n\n\n<label style=\"font-size: 20px;font-weight: 600\">Doctor details<\/label>\n\n<label style=\"margin-left:-15px\"><span class=\"wpcf7-form-control-wrap\" data-name=\"mostrar-dades-metge\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"mostrar-dades-metge\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">The details are not the same as the requester's.<\/span><\/label><\/span><\/span><\/span><\/label>\n\n<div data-id=\"group-dadesMetge\" data-orig_data_id=\"group-dadesMetge\" class=\"\" data-class=\"wpcf7cf_group\">\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label> Full name of the responsible doctor*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"nom-metge-responsable\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom-metge-responsable\" \/><\/span> <\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\"> \n<label> Email address of the responsible doctor*:\n     <span class=\"wpcf7-form-control-wrap\" data-name=\"correu-metge\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-email wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-email\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"email\" name=\"correu-metge\" \/><\/span><\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\"> \n<label> Phone number of the responsible doctor*:\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-metge\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefon-metge\" \/><\/span> <\/label> \n\n<\/div>\n<\/div>\n<\/div>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Patient details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\">\n<label>Full name*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"nom-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"nom-pacient\" \/><\/span><\/label>\n\n<label>Phone number*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"telefon-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-validates-as-required wpcf7-text wpcf7-validates-as-tel\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefon-pacient\" \/><\/span><\/label>\n\n<label>Province*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"provicia-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"provicia-pacient\" \/><\/span><\/label>\n\n\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Sex*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"Sexe-pacient\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"Sexe-pacient\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Male\">Male<\/option><option value=\"Female\">Female<\/option><\/select><\/span><\/label>\n\n<label>Address at the time of admission*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"direccio-momentIngres-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"direccio-momentIngres-pacient\" \/><\/span><\/label>\n\n<label>Country of birth*:\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-naixament\">\n\n\t\t\t<input id=\"uacf7_countries_pais-naixament\" type=\"text\" aria-required=\"true\" aria-invalid=\"false\" name=\"pais-naixament\" class=\"wpcf7-form-control wpcf7-uacf7_country_dropdown wpcf7-validates-as-required uacf7_country_dropdown_with_flag\">\n\n\t\t\t<span><\/span>\n\n\t\t\t<div style=\"display:none;\">\n\t\t\t\t<input type=\"hidden\" id=\"uacf7_countries_pais-naixament_code\" data-countrycodeinput=\"1\" readonly=\"readonly\" placeholder=\"Selected country code will appear here\" \/>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\t\t<\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Age*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"edat-pacient\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-required wpcf7-validates-as-number\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"number\" name=\"edat-pacient\" \/><\/span><\/label>\n\n<label>Municipality*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"municipi-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"municipi-pacient\" \/><\/span><\/label>\n\n\n<\/div>\n<\/div>\n\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Medical details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\">\n<label>Form of TB*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"forma-TB\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"forma-TB\" \/><\/span><\/label>\n\n<label>Recommended regimen*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"pauta-recomenada\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"pauta-recomenada\" \/><\/span><\/label>\n\n<\/div>\n\n<div class=\"uacf7-col-4\">\n\n<label>Initial sputum smear microscopy*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"bacilloscopia-inicial\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"bacilloscopia-inicial\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Positive\">Positive<\/option><option value=\"Negative\">Negative<\/option><option value=\"Not performed\">Not performed<\/option><\/select><\/span><\/label>\n\n<label>Resistances*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"resistencies\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"resistencies\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n\n<div data-id=\"conditional-group-resistencies\" data-orig_data_id=\"conditional-group-resistencies\" class=\"\" data-class=\"wpcf7cf_group\">\n<label>Which resistance:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"text-resistencia\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"text-resistencia\" \/><\/span><\/label><\/div>\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Treatment start date*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-inici-tractament\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-required wpcf7-validates-as-date\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-inici-tractament\" \/><\/span><\/label>\n\n\n<label>Requires isolation*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"aillament\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"aillament\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n<\/div>\n<\/div>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Nursing details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\">\n<label>Mobility problems*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"problemes-mobilitat\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"problemes-mobilitat\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Food allergy or intolerance*:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alergia-intolerancia-alimentaria\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alergia-intolerancia-alimentaria\" \/><\/span><\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Oxygen therapy*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"oxigeno-terapia\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"oxigeno-terapia\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Yes\">Yes<\/option><option value=\"No\">No<\/option><\/select><\/span><\/label>\n<\/div>\n<\/div>\n\n<label>Comments\n<span class=\"wpcf7-form-control-wrap\" data-name=\"comentaris\"><textarea cols=\"40\" rows=\"10\" maxlength=\"2000\" class=\"wpcf7-form-control wpcf7-textarea\" aria-invalid=\"false\" name=\"comentaris\"><\/textarea><\/span><\/label>\n\n<label style=\"margin-left:-15px\"><span class=\"wpcf7-form-control-wrap\" data-name=\"mostrar-camps-opcionals\"><span class=\"wpcf7-form-control wpcf7-acceptance optional\"><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"mostrar-camps-opcionals\" value=\"1\" aria-invalid=\"false\" \/><span class=\"wpcf7-list-item-label\">Add additional information.<\/span><\/label><\/span><\/span><\/span><\/label>\n<div data-id=\"group-info-adicional\" data-orig_data_id=\"group-info-adicional\" class=\"\" data-class=\"wpcf7cf_group\">\n\n<label style=\"font-size: 20px;font-weight: 600\">Requester details<\/label>\n\n<label> Other relevant phone numbers (Specialists):\n    <span class=\"wpcf7-form-control-wrap\" data-name=\"telefons-interes\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"telefons-interes\" \/><\/span> <\/label>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Patient details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\"> \n<label>Country of origin (Country the patient has recently come from):\n\t\t<span id=\"uacf7_country_select\" class=\"wpcf7-form-control-wrap pais-origen-pacient\">\n\n\t\t\t<input id=\"uacf7_countries_pais-origen-pacient\" type=\"text\" aria-invalid=\"false\" name=\"pais-origen-pacient\" class=\"wpcf7-form-control wpcf7-uacf7_country_dropdown uacf7_country_dropdown_with_flag\">\n\n\t\t\t<span><\/span>\n\n\t\t\t<div style=\"display:none;\">\n\t\t\t\t<input type=\"hidden\" id=\"uacf7_countries_pais-origen-pacient_code\" data-countrycodeinput=\"1\" readonly=\"readonly\" placeholder=\"Selected country code will appear here\" \/>\n\t\t\t<\/div>\n\n\t\t<\/span>\n\t\t<\/label>\n\n\n<label>Date of arrival to live in Spain:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-arribada-espanya-pacient\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-arribada-espanya-pacient\" \/><\/span><\/label>\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>CIP:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"cip-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"cip-pacient\" \/><\/span><\/label>\n\n<\/div>\n\n<div class=\"uacf7-col-4\">\n<label>Other phone numbers:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"altres-telefons-pacient\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-tel wpcf7-text wpcf7-validates-as-tel\" aria-invalid=\"false\" value=\"\" type=\"tel\" name=\"altres-telefons-pacient\" \/><\/span><\/label><\/div>\n<\/div>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Medical details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-6\"> \n<label>Symptom onset date:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"data-inici-simptomes\"><input class=\"wpcf7-form-control wpcf7-date wpcf7-validates-as-date\" aria-invalid=\"false\" value=\"\" type=\"date\" name=\"data-inici-simptomes\" \/><\/span><\/label> \n<\/div>\n\n<div class=\"uacf7-col-6\"> \n<label>Allergy and\/or intolerance to any medication\n<span class=\"wpcf7-form-control-wrap\" data-name=\"alergia-intolerancia-medicament\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"alergia-intolerancia-medicament\" \/><\/span><\/label>\n<\/div>\n<\/div>\n\n\n<label>Risk factors*<\/label><span class=\"wpcf7-form-control-wrap\" data-name=\"factors-risc\"><span class=\"wpcf7-form-control wpcf7-checkbox wpcf7-validates-as-required\"><span class=\"wpcf7-list-item first\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"HIV\" \/><span class=\"wpcf7-list-item-label\">HIV<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Diabetes\" \/><span class=\"wpcf7-list-item-label\">Diabetes<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Alcoholism\" \/><span class=\"wpcf7-list-item-label\">Alcoholism<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Drug abuse\" \/><span class=\"wpcf7-list-item-label\">Drug abuse<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Smoking\" \/><span class=\"wpcf7-list-item-label\">Smoking<\/span><\/label><\/span><span class=\"wpcf7-list-item\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Immunosuppressive treatment\" \/><span class=\"wpcf7-list-item-label\">Immunosuppressive treatment<\/span><\/label><\/span><span class=\"wpcf7-list-item last\"><label><input type=\"checkbox\" name=\"factors-risc[]\" value=\"Others\" \/><span class=\"wpcf7-list-item-label\">Others<\/span><\/label><\/span><\/span><\/span>\n\n<div data-id=\"conditional-group-factors-risc\" data-orig_data_id=\"conditional-group-factors-risc\" class=\"\" data-class=\"wpcf7cf_group\">\n<label>Specify others:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"factors-risc-altres\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"factors-risc-altres\" \/><\/span><\/label><\/div>\n\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Nursing details<\/label>\n\n<label>Barthel\n<span class=\"wpcf7-form-control-wrap\" data-name=\"barthel\"><input class=\"wpcf7-form-control wpcf7-number wpcf7-validates-as-number\" min=\"0\" max=\"100\" aria-invalid=\"false\" value=\"0\" type=\"number\" name=\"barthel\" \/><\/span><\/label>\n\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Social details<\/label>\n\n<div class=\"uacf7-row\">\n<div class=\"uacf7-col-4\">\n<label>Language barrier\n<span class=\"wpcf7-form-control-wrap\" data-name=\"barrera-idiomatica\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"barrera-idiomatica\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Total\">Total<\/option><option value=\"Partial\">Partial<\/option><option value=\"None\">None<\/option><\/select><\/span><\/label>\n\n<label>Housing:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"domicili\"><select class=\"wpcf7-form-control wpcf7-select wpcf7-validates-as-required\" aria-required=\"true\" aria-invalid=\"false\" name=\"domicili\"><option value=\"\">&#8212;Please choose an option&#8212;<\/option><option value=\"Fixed address\">Fixed address<\/option><option value=\"No fixed address\">No fixed address<\/option><option value=\"Homeless\">Homeless<\/option><\/select><\/span><\/label>\n\n\n<\/div>\n<div class=\"uacf7-col-4\">\n<label>Family situation:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"situacio-familiar\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"situacio-familiar\" \/><\/span><\/label>\n\n<\/div>\n<div class=\"uacf7-col-4\">\n<label>Employment situation:\n<span class=\"wpcf7-form-control-wrap\" data-name=\"situacio-laboral\"><input size=\"40\" maxlength=\"400\" class=\"wpcf7-form-control wpcf7-text\" aria-invalid=\"false\" value=\"\" type=\"text\" name=\"situacio-laboral\" \/><\/span><\/label>\n\n<\/div>\n<\/div>\n\n\n<\/div>\n\n<label style=\"font-size: 20px;font-weight: 600;margin-top:20px\">Documentation<\/label>\n\n<label>Medical report*\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-medic\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-medic\" \/><\/span><\/label>\n<label>National ID (DNI)\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-dni\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-dni\" \/><\/span><\/label>\n<label>CIP\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-cip\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-cip\" \/><\/span><\/label>\n<label>Social report\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-social\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-social\" \/><\/span><\/label>\n<label>Nursing report\n<span class=\"wpcf7-form-control-wrap\" data-name=\"file-informe-infermeria\"><input size=\"40\" class=\"wpcf7-form-control wpcf7-file wpcf7-validates-as-required\" accept=\"audio\/*,video\/*,image\/*\" aria-required=\"true\" aria-invalid=\"false\" type=\"file\" name=\"file-informe-infermeria\" \/><\/span><\/label>\n\n\n<input class=\"wpcf7-form-control wpcf7-submit has-spinner\" type=\"submit\" value=\"Submit\" \/><\/div><\/div><div class=\"wpcf7-response-output\" aria-hidden=\"true\"><\/div>\n<\/form>\n<\/div>\n<\/div>\n\t\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t\t\t<\/div>\n\t\t","protected":false},"excerpt":{"rendered":"<p>Patient admission Clinic Admission Form<\/p>\n","protected":false},"author":2,"featured_media":0,"parent":0,"menu_order":0,"comment_status":"closed","ping_status":"closed","template":"","meta":{"_acf_changed":false,"inline_featured_image":false,"footnotes":""},"class_list":["post-6145","page","type-page","status-publish","hentry"],"acf":[],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>\u25b7Clinic Admission - \u3010 Serveis Cl\u00ednics \u3011<\/title>\n<meta name=\"description\" content=\"Patient admission     Clinic 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