Pre-Admission Form

All items marked with a * are required fields.

Cure Day Hospitals

Hospital

Patient’s details

Title

Initials

Full names

Surname

Sex

Male Female

Date of birth

Preferred language

Nationality

Dependant code

ID No

Cell

Work Number

Allergies

Please select you dietary requirements

If none please state N/A or None.

Street Address

Suburb

City

Province

Area code

Relationship to Main Member

Patient's Employer’s Detail

Occupation

Company name

Tel

Supporting Documentation

Upload Identifiction (ID)

Upload Medial Aid Card

Upload Documentation

The maximum file size per document is 10 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?

Name & Surname

Tel No

Address

Doctor’s information

Name of Dr

Practice No

ICD Code (provided by your Doctor or Medical Aid)

Procedure

Date of Procedure

Medical Aid Information

Medical Fund

Member No

Medical Aid Fund Plan

Authorization No

Person responsible for account

Main member of Medical Aid

Person responsible for the account is also the patient

Title

Initials

Full Names

Main member’s surname

Street Address

Suburb

City

Province

Area code

Cell

Work Number

Occupation

Employer

Next of kin

Person to contact in case of emergency

Title

Surname

Initials

Cell

Work Number

Relationship to patient

Declaration

Main member / Person responsible for account

Full names & Surname

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

Date

Confirm details

I hereby confirm all details supplied on this form are correct.

Signature

Pre-Admission Form

Cure Day Hospitals

Patient’s details

Patient's Employer’s Detail

Supporting Documentation

Referring GP/Dentist

Doctor’s information

Medical Aid Information

Person responsible for account

Next of kin

Declaration

Quick Links

Head Office

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