Pre-Admission Form

All items marked with a * are required fields.

Cure Day Hospital

Patient’s details

If none please state N/A or None.

Supporting Documentation

The maximum file size per document is 3 MB. The file types allowed are: pdf, jpeg, jpg or png.

Referring GP/Dentist

Which GP/Dentist referred you to your operating specialist, if applicable?

Doctor’s information

Medical Aid Information

Person responsible for account

Main member of Medical Aid

Employer’s Detail

Main member of Medical Aid

Next of kin

Person to contact in case of emergency

Declaration

Main member / Person responsible for account

give Cure Day Hospital the authority to claim/submit the account (s) on my behalf to (Medical Aid)
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