App Form for Hospitalisation - Sinhala

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    08-Jul-2016

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Agrahara Form

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  • ffjoH yd mqoa., yosis wk;=re rlaIK l%uh

    ysulus b,a,qus m;%h ^w.%ydr&

    ^b,a,q m;%h msrug fmr f iu. we;s Wmfoia m;%sldj lshjkak'&

    1' b,a,quslre ms

  • 4' rCIK m%%;s,dN lrkafka ()Tng fyda l,;%hdg fkd k wod, fldgfia ^& fhdod lrkaak'

    4'1 orejkag( ujg( mshdg(

    4'2'1 Tyqf.a$wehf.a ku()'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

    4'2'2 Tyqf.a$wehf.a Wmka oskh () ''''''''''''''''''''''''''''''''''' jhi '''''''''''''''''''''''' /lshdj'''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

    5 m%;sldr ms,sno ia;r (- 5'1 frda.h fyda Y,Hluh (- 5'2 wfmalaIs; ysl uqo, (-

    6' nexl= .sKq ms,ssn iaa;rh () ^Tnf.a fm!oa.,sl nexl= .sKqu - cd;sl b;srs lsrSf nexl=j " uyck nexl=j " ,xld nexl=j " im;a nexl=j " fldurAI,a nexl=j" fi,dka nexl=j "yegka keIk,a nexl=j " fkaIka g%ia nexl=j " cd;sl ixjraOk nexl=j " mEka tAIshd nexl=j " fydxfldx weka Iekayhs nexl=j iagEkav pdg nexl=j hk nexl=j,g wh;a .sKqula h hq;=h&

    5'1 nexl= .sKq i|yka Tnf.a ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''

    5'2 .sKq wxlh 5'3 nexl=f ku(- ''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''''' nexl= YdLdj(- ''''''''''''''''''''''''''''''''''''''''''''''''''

    7' fuu whm;g wod, ho fjk;a wdh;khlska m%;smQrAKh lr ;sf k fyda whlr ;sf k 7'1 wdh;kfha ku iy ,smskh (- 7'2 f.jq uqo, (- 7'3 ysl wxlh$fhduq wxlh (-

    8' w.%ydr rlaIK l%uh hgf;a Tn ,ndf.k we;s m%;s,dN ms,sno ia;r

    ysl j.h osskh ,enQ uqqo, weia lKaKdvs ore Wm;a fjk;a frda.$ ie;al

    9' whlref.a m%l%ldYh by; ioyka f;dr;=re i;H yd ksjros nj;a" fuu ysslmEu by; 07 fcaohg hg;aj fjk;a rlaIK wdh;khlska" fjk;a l%uhla u.ska fyda ta ioyd b,a,Sula bosrsm;alr fyda fkdue;s nj uu fuhska iy;sl fj' udf.a l,;%hd iska fyda f fjkqfjka lsisoq rlaIK m%;s,dNhla ,nd fyda b,a,Sula bosrsm;a lr fkdue;s njg;a uu iy;sl fj' rdcH mrsmd,k pl%f,aLk wxl 12$2005 ys 08" iii j.ka;sh m%ldr jHdc f,aLK bosrsm;a lsrSfuka yslmdkq ,nk ks,OdrShd jeroslrefjl= jqjfyd;a wdh;k ix.%yfha ii lKavfha XLViii jeks mrsfPaofha Odk yd oKavkS;S ix.%yfha Odko wkqj l%shd lrkq ,nk nj uu oks' ysl f.u wxl 06 hgf;a i|yka nexl= .sKqug ner lrk f,i b,a,d is' oskh

    whlref.a w;aik

    " " fld

  • by; ia;r ioyka uy;d$uy;ahf.a rlaIK yslu wjYH lghq;= ioyd ksfoaYlr f iu. bosrsm;a lr' by; ioyka f;dr;=re i;H yd ksjros nj;a " Tyqf.a $wehf.a fm!oa.,sl ,smsf.dkqj wkqj

    iy;sl lr' rlaIs;hd m%;sldr ,en frdayf,ka neyerjq udihg fmr udih jq udifha odhl uqo, whlr nexl=f .......................YdLdf wxl ...................... orK fplam;ska cd;sl rlaIK Ndr wruqof,a uyck nexl=f /csk YdLdf 033-2-001-2-2467951 orK .sKqug nerl< remsh,a ....................... l uqM uqo,g we;=,;a lr we;'

    w;aik .......................

    ku .

    ;k;=r

    oskh ....................... ^ks, uqj ;eu w;HjYHhhs&

    11' frda.sshdf.a ffjoHjrhd$Y,H ffjoHjrhd iska imQQrAK l< hq;qh'

    Should be filled by the Medical Officer/Surgeon of the patient.

    11'1 frda.shdf.a ku

    Name of the Patient :.. 11'2 frda. ksYaph

    .. Diagnosis of disease:.. ....

    11'3 idudkH rdcldrS lghq;= j, ksr;ug fkdyels ld, iSudj (- .osk isg..osk olajd Period unable to attend to usual business/works: From:-. To-.

    11'4 frday,g we;=,;a l, oskh (-. msgjq oskh (- If admitted to the hospital, Date of admission.. Date of discharge..

    by; ioyka frda.shdf.a ffjoHjrhd$Y,H ffjoHjrhd ud nj;a" fuu b,a,Su inkaOjQ fiajdj uu wkqu; l, nj;a iy;sl lr'

    frda.shdg m%;sldr l, ffjoHjrdf.a$ fYaI{ ffjoHjrhdf.a w;aik yd ks, uqdj

    oskh (- I hereby certify that I am Medical Officer/Surgeon of the above named patient and approve submission with regard to this claim. Date

    Signature of Medical Officer/Surgeon whm; imQrAK imQrQrAKAK lsrsrSuSu i|yd Wmfoia

  • ^fmdararu wxl A I frday,a .; yd ie;al " yDo ie;al " ore Wm;a" weia lKaKdvs"s" ms