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: _______________________________________