Hospital Admissions

Those who wish to complete the admission form online are welcome to do so by following the instructions below. Online pre-admission is provided as a courtesy to our patients. Please remember to visit hospital Reception at your first opportunity to provide the required signature. If you wish to print an admission form, please click here to download an a printable Admission Form (as an Acrobat PDF).

When you visit the hospital for admittance purposes please remember:
  • If you are a medical aid patient, please bring your ID document, medical aid card and pre-authorisation number with you.
  • Private patients are kindly reminded to make deposit arrangements on admission and to settle their account in full when they are discharged.

Please ensure that you fill in all lines marked with an *. If you are entirely unable to provide the information now, then you may bring the details with you and provide it on admission. In that case, enter ‘on admission’ in the relevant line(s).

1.1 Surname:*

1.2 First Names:*

1.3 Title:*

1.4 Home Address (Not box No.):*

City/suburb:*

1.5 Postal Address:*

City/suburb:*

Postal code:*

Home Telephone or cellphone:*

E-mail address:

1.6 Occupation:*

1.7 Home Language:*

1.8 Employers Name:

Employers Address:

City/suburb:

Postal code:

Work Telephone:

1.9 Date of birth: DD/MM/YYYY*

1.10 Marital Status:*

1.11 Antenuptual Contract:*

 No    Yes    Not applicable 

1.12 I.D. Number:*

1.12 Religion:

1.14 Name of next of kin not living with you:*

Address of next of kin in 1.14:*

Relationship of kin in 1.14:*

1.15 Referring Doctor:*

1.16 Attending Doctor:*

1.17 DIAGNOSIS:*

1.18 Anaesthetist:

1.19 Allergies:*

NB:  Please enter ‘private’ in all three blanks if not on a medical aid

1.20 MEDICAL AID NAME:*

1.21 MEDICAL AID PLAN:*

1.22 MEDICAL AID NO:*

1.23 Date of joining Medical Aid Scheme:  DD/MM/YYYY

Please note that accounts are submitted directly to the relevant Medical Aid.  Copies of accounts are available on request.

 

2. PERSON RESPONSIBLE FOR ACCOUNT (IF DIFFERENT FROM ABOVE)

2.1 Surname:

2.2 First Names:

2.3 Title:

2.4 I.D. No.:

2.5 Occupation:

2.6 Home Address (Not Box No.):

City/suburb:

Tel (H):

2.7 Postal Address:

City/suburb:

Code:

2.8 Employer’s Name:

Employer’s Address:

City/suburb:

Code:

Tel (w):

2.9 In the case of a refund, in whose name must the cheque be made out to?

Initials:

Surname:

 

 

Comments or questions for the admissions clerk:

Accept:*  

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