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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:

  1. Please download, read and sign the “Terms and Conditions for Admissions Document”. 
    1. English: Terms and Conditions for Admission.  Download here.  
    2. Afrikaans: Terme en Voorwaardes vir Opname. Laai hier af.
  2. Documentation:
    1. ID/Passport (non-SA resident) and Medical Aid Card
    2. Doctor’s admission form with codes
    3. Authorisation documentation from your funder
  3. Co-payments:
    1. Confirm all co-payments and shortfalls with your funder.  Co-payments and/or shortfalls are payable on admission
  4. Medication:
    1. Please bring your current chronic medication with. 

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.