ADMISSION.NO: __________________________

DATE: ___________________ TIME: __________

Pre-Admission /Admission Manual Form

PATIENT DETAILS

Title: ___________ Surname: _______________________________________________________

First name: ___________________________________________ Gender: Male Female

Date of Birth: ______________ ID.NO: ______________________________ Religion: _________

Home Tel: __________________________ Cell: _______________________________

Physical address: __________________________________________________________________

_____________________________________________________________ Code: _______________

Postal address: ____________________________________________________________________

________________________________________________________________Code: ___________

Employment information
Name of Company: ________________________________________________________________

Work address: ____________________________________________________________________

Occupation____________________________________________ Work Tel: __________________

NEXT OF KIN (not main member / Guarantor)

Title: __________ Initials: __________ Surame: ____________________________________

Cell no: ___________________________ Relationship: ________________________________

ADMISSION DETAILS

Admitting DR: ________________________________ Ref Dr: _____________________________

Patient Diagnosis: ____________________________________________ Date of adm: ________________________

ICD10 codes: ___________________________________________________ Ward: ____________

Procedure Codes: __________________________________________________________________

MEDICAL AID DETAILS

Medical Aid Insurance: ___________________________________________________________

Medical Aid Number: ________________________ Plan/option: ______________________

Authorization Number: __________________________________________ DEP.CODE: _______

MAIN MEMBER /GUARANTOR DETAILS

Title: ___________ Surname: _______________________________________________________

First Name: ___________________________________________ Gender: Male Female

Date of Birth: _______________________ ID.NO: _______________________________________

Email address: ___________________________________________________ Occupation: ________________

Home Tel: _________________ Cell.No: __________________ Work Tel: __________________

Admission Form signed by ________________________________________ (patient/guarantor/
guardian) on _____________________________________20____

Patient/Guarantor: _____________________________________

Admission Clerk: _______________________________________

Refer a Patient

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Please Contact Me

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Please Contact Me

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