MEDICALFACILITYQUESTIONNAIRE

NameoftheFacility

GENERALOVERVIEW
ProviderType

TypeofCare

Hospital

Public

OutpatientFacility

Private

SOSClinic

SemiPrivate

Inpatientcare

HealthCheck/Occupational

OutpatientCare

Housecall

Emergency/Trauma

MultiSpecialty

Yes

Emergencyroom

open24/7

PhysicalAddress
AddressL1
AddressL2
City
State/Province
PostalCode
Country

Mailing/PostalAddress
AddressL1
AddressL2
City
State/Province
PostalCode
Country

MEDICALFACILITYQUESTIONNAIRE
GENERALOVERVIEW
BillingAddress
AddressL1
AddressL2
City
State/Province
PostalCode
Country

MainContactDetails
MainPhoneNumber
MainFaxNumber
MainEmailAddress
Website

Yes

ParkingAvailable

No

Proximity

Near Airport: ..km.minutes drive

NearCityCentre
NearestHotel:........
NearestMetro,TrainorBusStation.
Other(Specify)

MEDICALFACILITYQUESTIONNAIRE
IMPORTANTCONTACTS
MainAdministrativeContact
Name
Title/Position
TelephoneNumber
FaxNumber
EmailAddress
MedicalDirector
Name
Title/Position
TelephoneNumber
FaxNumber
EmailAddress

GENERALINFORMATION
Languagesspokenbystaff

Arabic

English

French

German

Italian

Japanese

Portuguese

Spanish

Other(specify)

Yes

Doyouhaveaccesstointerpreterservices?

No

Ifyes,whatlanguagesdotheyoffer?

Arabic

English

French

German

Italian

Japanese

Portuguese

Other(specify)

DoyouhaveOutpatientsDepartment?

Yes

No

Yes

No

AreAppointmentsRequired?

MEDICALFACILITYQUESTIONNAIRE
GENERALINFORMATION

OpeningDays&Hours

Monday

openinghours:

Tuesday

openinghours:

Wednesday

openinghours:

Thursday

openinghours:

Friday

openinghours:

Saturday

openinghours:

Sunday

openinghours:

FINANCIALINFORMATION

MainFinanceContact

Name

Title/Position
TelephoneNumber

FaxNumber

EmailAddress

DoyouAcceptGuaranteeofpaymentfrom
InternationalSOS?
IfYes,aretheyfor?

Yes

No

InpatientCare

OutpatientCare

DoyouacceptAuthorizationLetterfrom
InternationalSOSforTRICAREbeneficiaries?

Yes

No

NOTE:(TheAuthorizationletterisissuedforTRICARE
beneficiaries.TRICAREisthehealthcareprogramserving
UniformedServicemembersandtheirfamiliesworldwide.)

IfYes,aretheyfor?

DoyouAcceptCreditCards
IfYes,whichones?

InpatientCare
Yes
Amex
Master
Other

PreferredpaymentOption

TotalNumberofBeds

Cheque

OutpatientCare

No
Diners
Visa

JTB

ElectronicTransfer

MEDICALFACILITYQUESTIONNAIRE
MEDICALSPECIALITIES

MAINDEPARTMENTS/
SERVICES
AirportClinic
Anesthesia
AviationMedicine
Cardiology
Dermatology
Dialysis
DiveChamber
ENT(otolaryngology)
FamilyMedicine
Gastroenterology
Imaging
Internalmedicine
LongTermCare
OB/GYN
Oncology
Psychiatry
Others

MEDICINE
Endocrinology
Genetics
InfectiousDiseases
OccupationalMedicine
Nephrology
Neurology
RehabilitationMedicine
Rheumatology
RespiratoryMedicine
TropicalMedicine

SURGERY
CardiothoracicSurgery
Colorectalsurgery
Faciomaxillary
HandSurgery
Neurosurgery
OrthopedicSurgery
PlasticSurgery
Transplantsurgery
Urology
Vascular
Others

OPHTHALMOLOGY
Retinal
Neuroopthalmology

OTHER
BurnsUnit
Groundtransportation
Laboratory
Pharmacy

Completenextsectionifapplies:

PEDIATRICS
General
Neonatology
PediatricCardiology
PediatricGenetics
Pediatricorthopedic
Surgery
Pediatricurology
PediatricAllergy
PediatricNephrology
PediatricPulmonology/
RespiratoryMedicine
PediatricAnesthesiology
PediatricNeurology
PediatricSurgery
PediatricGastroenterology
PediatricEndocrinology

DENTAL
General
Endodontics
Orthodontics
Periodontics
Pediadontics
Prosthodontics

MEDICALFACILITYQUESTIONNAIRE
MEDICALSPECIALITIES
PARAMEDICALSERVICES

Acupuncture
Audiology
Chiropractic
Dietetics
OccupationalTherapy
Optometry
Osteopathy
SocialWork

Physiotherapist
Podiatry
Prosthetics
Psychologist
Speechpathology
SleepLaboratory
Counseling

Please,completenextsectionifapplies

MEDICALHEALTHCHECK
Alcoholscreening
(breathalyser)
Audiometry
Cardiacfunction_ECG
Colonoscopy
Drugscreening(laboratory
analysis)
Gastroscopy
Physicalexamination&vital
signs
RespiratoryFunction_Peak
ExpiratoryFlowRate
Serology:HBsAg
Serology:HepatitisC
SerologySyphillis
(VDRL/TPHA)
UrineHeavyMetal
Urinetest:Chlamydia

Alcoholscreening(laboratory)
Auditorytest
Cardiacfunction_Stress
Echocardiogram
Dentalcheckup
Drugscreening(urine
dipstick)
MantouxTestorEquivalent
Physiotherapyassessment
Respiratory
Function_Spirometry
Serology:HepatitisAIgG
Serology:HIVELISA(with
counselling)
Stoolculture
Urinetest(dipstick)

Alcoholscreening(saliva)
Cardiacfunction:Stress
ECG
Cardiovascularrisk
assessment
(e.g.Framinghamscore)
Faecaloccultbloodtest
(FOBT)
Pap/CervicalSmear
PSA(withcounselling)
Serology:AntiHBs
Serology:HepatitisAIgM
Serology:Quantiferon
(R)test
UrineDrugScreening
Urinetest(microscopy
andculture)

MEDICALFACILITYQUESTIONNAIRE

Completenextsectionifapplies:

VACCINATIONS
Doyouoffervaccinations?
IfYes,whichones?

Yes No

StandardVaccinations

Diphtheria
MMR(Measles,Mumps,
HepatitisA Rubella)
HepatitisB
Polio
Influenza
Tetanus
Meningitis(A,C,Y,W125)
Typhoid(oralorinjection)
Pertussis(WhoopingCough)
Varicella
Pneumococcal

SpecificVaccines

BCG
Rabies
Cholera
TickborneEncephalitis
JapaneseBencephalitis
YellowFever
Leptospirosis

DOCUMENTATION
Pleaseprovidethefollowingdocuments:
CopyoffacilityLicense

Yes

No

CopyoftheMalpracticeInsurance

Yes

No

ListofDoctors

Yes

No

PriceList

Yes

No

CopiesofExternalaccreditation

Yes

No

Date:

PrintName:

Signature: