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PRE-ADMISSION FORM

On admission to the hospital, patients are requested to produce I.D's of patient and principal member of medical aid as well as copy of medical aid card.

Patients are requested beforehand to obtain necessary authorization numbers from their medical aids for all admissions to the hospital, i.e. All medical and surgrical admissions. PS: authorization remains the patient's responsibility.

It is advisable to hand in all valuables and cellular phones at reception. This rule applies to Day Theatre cases as well.

Telephone facilities are available in our medical and surgical wards. These are obtainable from the reception at a cost of R20,00 which is a non-refundable deposit.

Please fill in the hospital pre-admission form 48hours prior to admission. Medical Aid card and Identity document must be produced on admission.

1) Hospital Of Admission:



2) Personal Information:

Surname Initial Title Gender
Firstname Tel Age
ID No Religion
Language D.O.B date of birth


Address Code
Postal Address Code
Business Address Code
Occupation
Business Name / Name of Employer


Next of kin Relationship Tel
Address
Other Contact Relationship Tel
Address


3) Medical Aid Information:

Medical Aid Name Medical Aid Number
Plan/Option Confirmation No
Authorisation No Length Of Stay days


I have confirmed medical aid coverage?


4) Doctor/Hospital Information:

Admitting Doctor Referring Doctor
Date of admission Time of admission
Reason for admission
Is this admission due to an injury?
Maternity: Expected date of delivery


5) Member responsible for account:

Same as the details provided above

Name & Surname Initial Title Gender
Relationship Tel
ID No
Occupation
Business Name / Name of Employer
Address Code


 
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