PATIENT ADMISSION FORM

Please complete your Pre-Admission 48 hours prior to admission

ON THE DAY OF ADMISSION, PLEASE BRING THE FOLLOWING:

  • ID/Passport (non-SA resident) and Medical Aid Card
  • Doctor’s admission form with codes
  • COVID-19 negative results (hard copy not older than 48 hours)
  • Authorisation documentation from your funder
  • Confirm all co-payments and shortfalls with your funder.¬† Co-payments and/or shortfalls are payable on admission


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 form must be completed accurately before submission.
Please ensure that your ID number is clearly indicated.