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Testimonials

Dear Management: I have a great fear of Anaesthesia and operations in general. I was, however, surprised by the professional way I was treated by everyone at your hospital. If I ever need another operation, I will demand to have it done at the Zuid-Afrikaans Hospital. You can be proud of your staff, doctors and anaesthetists. Well done!
- Mr. T. Stoffberg

Online Patients Form

Complete the below online form

Please note that fields in bold are compulsory.

Section A: Person responsible for account (Account holder)

Surname:

Initials:

Title:

Postal address:

Postal address 2:

Postal address 3:

Postal code:

Tel. home:

Tel. work:

Mobile:

I.D. no:

Relationship:

Profession:

Employer:

Medical aid:

Member no:

Option:

Date of enrolment:

Authorisation no:

Email:

Section B: Patient admission

Surname:

Initials:

Sex:

Language:

Postal address:

Postal address 2:

Postal address 3:

Postal code:

I.D. no:

Date of birth:

Tel. home:

Tel. work:

Mobile:

Religion:

Congregation:

Profession:

Employer:

Family doctor:

Referring doctor:

Next of kin

Name:

Surname:

Postal address:

Postal address 2:

Postal address 3:

Postal code:

Tel. home:

Tel. work:

Contact person

Name:

Surname:

Postal address:

Postal address 2:

Postal address 3:

Postal code:

Tel. home:

Tel. work:

Bank details

Account holder:

Bank:

Branch code:

Account number:

Account type:

Ward type:

I hereby accept the Terms & Conditions:

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