Pre-Admission Form

Patient Information

Full Names
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Surname
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ID Number
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Cell Phone Number
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Home and Work Telephone Number
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Home Address
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Postal Address
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Email Address
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Company Name and Address
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Occupation
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Medical Aid Details

Medical Aid
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Medical Aid Number
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Plan
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Dependent Code (Patient)
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Main Member Details

Main Member Dependent Code
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Full Names
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ID Number
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Email Address
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Cell Phone Number
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Home and Work Telephone Number
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Company Name and Address
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Occupation
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Next Of Kin

Contact Person 1
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Relationship
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Telephone Numbers
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Address
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Contact Person 2 (not living at the same address)
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Relationship
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Telephone Numbers
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Address
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Doctors Details

Admitting Doctor
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Referring Doctor
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Family/House Doctor
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Admission Details

ICD 10 Codes
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CPT4 codes
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Admission Date
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Authorisation Number
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Procedure/Diagnosis
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Co Payment
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I'm hereby confirm that above information is correct
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471 Kassier Road, Assagay, 3610

  • Hot line: +27 31 768 8000

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