Pre-Admission Form

Cure Day Hospital

Referring GP/Dentist

Doctor’s information

Patient’s details

The maximum file size per document is 2 MB. The file types allowed are: pdf, jpeg, jpg or png.

Person responsible for account

Main member of Medical Aid

Employer’s Detail

Main member/Person responsible for account

Next of kin

Person to contact in case of emergency


Main member / Person responsible for account

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