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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.