Kopila - The Well Baby Clinic
Dear Parents,
Thank you for choosing Kopila Clinic. Your child's health is very important to us, and we want to
make your visit as smooth as possible. Kopila Clinic is committed to provide you with the highest quality
professional medical care for your child.
Please complete the registration form (page 4) and Kopila Medical Record Book (pages 2-3 & 52-53)
provided to you. Please also review the enclosed information thoroughly.
During your visit, please expect three main activities:
Registration: You need to fill out the registration form and Kopila's Medical Record Book so that
the registration information could be processed. You do not need to return back the first and second pages
of the Registration Form as these pages are for your reference. The whole registration process may take
about 30 minutes.
Examination: Your child's height, weight and head circumference will be recorded and immunization
status will be evaluated by a nurse. After that, your child will be seen by the doctor.
Checkout: After processing record on your child's visit, follow-up appointments for future check-ups
and immunization dates will be scheduled. Finally medication will be dispensed to you as per
prescription of the doctor.
We hope your visit to the clinic is a positive experience. Please contact the clinic at 977-1-5542767 (24
hrs. Hot line) if you have any questions prior to your next visit or if you have immediate concern during
off- hours. We look forward to helping you.
Sincerely,
Kopila Team
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WHAT WE ARE
! KOPILA is a well baby clinic. We do not have inpatient facility. Children who follow our "Well Baby" protocol
normally do not need hospitalization. However, if children need Hospital care, we give guidance and assistance
in hospitalization process.
! We see children from birth to 18 years of age.
! We provide Pediatric Consultation, Eye Consultation, Immunization, Pharmacy and Pathology Lab.
We also provide Counseling on Growth and Development, Nutrition, Behavior Problem, Poor School
Performance and other Childhood Related Concerns.
! We are open for immunization every day. Please avail our combination vaccines and avoid several needles.
! We also encourage adults to immunize against fatal diseases. Please consult us for information on Adult
Immunization Program and take necessary vaccines to prevent life threatening diseases.
! Eye Screening test is done on each well baby checkups.
! We provide "24-hours emergency telephone service" to Kopila members. This means, your call will be attended
with utmost urgency by qualified and trained Kopila Staffs on duty and you will be guided on how to manage
your child’s problem until attended by a doctor (next day) or at the hospital (if need be). Please note: This does
not mean, a doctor of your choice will be available to attend your call at that particular time.
DOs and DON’Ts of Kopila
! You must bring your Kopila Medical Record Book on every visit. In case you forget to bring the Book, we
encourage you to buy a new one before consultation. Without the Book, you will lose privilege of getting service.
! Always keep your Kopila ID number handy. Whenever you need Kopila’s service (even while taking an
appointment), you will be asked your Kopila ID number.
! We are not bound to provide any documents other than the invoice. You will receive an invoice while checking out.
If you need any other documents or a re-print of previous invoices for insurance purpose, documentation fee will
be separately charged.
! Take prior appointment for Consultation and Vaccination.
! Make sure you cancel/reschedule the appointment, in case you can not make it (atleat 24 hours in advance),
or if you are running late.
! Please inform us when you have a new telephone number. Telephone service is one of the hall marks of
Kopila Clinic and we are helpless when we are left with old unused telephone numbers. Few examples of our
telephone services are: follow up for related illness, updating vaccination schedule and reminder for eye screening
test.
Please write your valuable comments, Kopila experience and suggestions on the Visitor’s
Book placed near the exit door. Kopila Team is committed to "Serve You Better".
Few minute of your time will enable us to measure if we have met our commitments.
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For Official Use Only. Please do not fill this out.
Name:
ID Number:
Consent Form for Adult Immunization
KOPILA-THE WELL BABY CLINIC offers various immunization for children and adult against diseases as per
immunization schedule recommended by CDC, USA and EPI, WHO for Nepal. It is advisable to increase your immunity
against these diseases.
Please complete this and forward this Consent Form to KOPILA.
I consent to receiving relevant immunization by KOPILA as indicated below:
• Tetanus/diphtheria (Td)/Tdap
• OPV/IPV (Polio)
• Measles,Mumps,Rubella (MMR)
• Hepatitis B
• Meningococcal A, C, W & Y
• Typhoid
• Hepatitis A
• Varicella
• Rabies
• Influenza
• Pneumococcal
• Japanese Encephalitis
• Yellow Fever
• Human Papilomavirus (HPV)
• Others……….
Recent/Major Illness: No Yes
Specify:
Is today a good day for vaccination?
Are you sick today?
Do you or any person who lives with you have Covid-19?
Do you have allergies to medications, food or any vaccine?
Did you have a serious reaction to a vaccination in the past?
Did you have a seizure in the past?
Do you or any person who lives with you have AIDS?
Do you suffer from any immune system issues, leukemia, or cancer?
Are you on cortisone, prednisone, or other steroids in the past three months?
Have you received a transfusion of blood or plasma, or been given immune (gamma) globulin in the
past? Do you have egg allergy/egg product allergy?
Name: Signature:
Date:
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KOPILA- The Well Baby Clinic
(Please print clearly and answer completely!)
PATIENT INFORMATION (CHILD'S) Nationality
NAME (First) (M.I.)
STREET ADDRESS CITY/
HOME PHONE
DATE OF BIRTH AGE MALE FEMALE
WHO REFERRED YOU TO US? PHONE
PERSON TO CONTACT (other than below) FOR EMERGENCY
NAME PHONE
1 PARENT INFORMATION (Mother) Nationality Other (guardian, adoptive parent, etc.)
NAME DATE OF BIRTH
*ADDRESS E-mail
(Complete street address) E-mail address in BLOCK
*PERSONAL PHONE WORK PHONE
(if different from above)
OFFICE NAME OCCUPATION
Office Address Do you have Health Insurance? Yes No
2 PARENT INFORMATION (Father) Nationality Other (guardian, adoptive parent, etc.)
NAME DATE OF BIRTH
*ADDRESS E-mail
(Complete street address) E-mail address in BLOCK
*PERSONAL PHONE WORK PHONE
(if different from above)
OFFICE NAME OCCUPATION
Office Address Do you have Health Insurance? Yes No
No Not Known Yes (Please specify any allergies below)
Allergies (Please specify) ......................................................................................................................................................
DO YOU LIVE/WORK IN NEPAL? YES NO
IF YOU ARE A VISITOR, WHERE ARE YOU STAYING WHILE YOU ARE HERE?
Address (Hotel/Apartment/Guest House/ ................................................................................................................................
Room ..................................... Telephone: .........................................
WHOM DO THE CHILDREN LIVE WITH?
OTHER CHILDREN (including last name if different)
NAME DATE OF BIRTH
NAME DATE OF BIRTH
NAME DATE OF BIRTH
Important: Please arrive at the clinic atleast 30 minutes before your scheduled appointment time to allow us
for proper registration and evaluation of past medical record and immunization status. Patients arriving late
may not be able to see the doctor and will need to be re-scheduled.
If you are unable to keep a scheduled appointment, please notify us as soon as possible. We maintain a proper list
of punctual patients who deserve a special services. Patients missing more than two appointments without proper
cancellation (at least one hour prior to appointment time) will be dismissed and not rescheduled.
Do you want us to give you reminder calls for your child's immunization schedule dates?
No, please do not remind us. Please remind us.
* WE CANNOT PROCESS THE REGISTRATION WITHOUT THESE INFORMATION.
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