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

ADMISSION DATE

Type of patient

Authorisation number (For private patients, please enter 'Not applicable')

Doctor

MAIN MEMBER/PERSON RESPONSIBLE FOR ACCOUNT

Is Main Medical Member and Patient the same person?

ID/Passport Number

Title

Surname

Full names

Gender

Relationship with patient

Physical home address

Suburb

Town / City

Postal code

Employer name

Mobile number

Postal address

Suburb

Postal code

Occupation

Work number

Email address

MEDICAL AID INFORMATION

Medical aid name

Membership number

Plan/Option

Dependant code

DETAILS OF PATIENT

ID/Passport Number

Title

Surname

Full names

Gender

Residential address

Suburb

Town

Postal code

Mobile number

Home number

Postal address

Suburb

Town

Postal code

Work number

Email address

BANKING DETAILS (For refund purposes)

Account name

Account number

Branch / Branch code

Type of account

RELATIVE

Name and surname

Relationship

Mobile number

Home number

Work number

Address

Suburb

Town / City

Postal code

CONTACT PERSON (Not the same as above)

Name and surname

Relationship

Mobile number

Home number

Work number

Address

Suburb

Town / City

Postal code

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.

SIGNATURE

Date completed

PATIENT ADMISSION FORM

Patient information

Disabled access and services

Our doctors

Visitors information

About us

Contact