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Pre-Admission Form

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