PATIENT ADMISSION FORM

Please complete this form if Patient and Main Medical Aid Member are NOT the same

Please note that this form must reach the hospital 48 hours prior to administration


Completed document, Medical Aid card and ID document must be submitted to Reception at least 48 hours prior to admission, if possible.



MAIN MEMBER/PERSON RESPONSIBLE FOR ACCOUNT



MEDICAL AID INFORMATION



DETAILS OF PATIENT



BANKING DETAILS (For refund purposes)



RELATIVE



CONTACT PERSON (Not the same as above)





PLEASE NOTE: It is essential that the above pre-admission from must be completed accurately before submission.
Please ensure that your ID number is clearly indicated.

Please note that this form must reach the hospital 48 hours prior to administration