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. 2x ID/Passport (non-SA resident) and Medical Aid Card
  3. Doctor’s admission form with codes
  4. COVID-19 negative results (hard copy not older than 48 hours)
  5. Authorisation documentation from your funder
  6. 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.