Online Pre-admission | Advanced Health

Online

Pre-Admission Form

What to bring

when you visit our hospital

Main member's ID Book

Patient's ID Book

Medical Aid Card

Doctor's letter of referral

Medical Aid Authorisation Number

We can assist with this if necessary

Online Pre-Admission Form

"*" indicates required fields

Day Hospital*

Doctor (De La Vie)

Doctor (Durbanville)

Doctor (East Rand)

Doctor (Groenkloof)

Doctor (Harbour Bay)

Doctor (Knysna)

Doctor (Medgate)

Doctor (Panorama)

Name of Doctor (Worcester)

Referring Doctor

Diagnosis

Procedure

Procedure if other

Date of procedure

Authorisation code

Diagnosis Code / ICD 10 code*

Primary CPT Doctors Codes

Patient Details - Please Complete

Name*

Title Initials Full Names Surname

Id Number

Passport Number

Gender*

Male

Female

Religion

Language

Nationality

Occupation

Allergies

Residential Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Postal Address

Street/Postal Address Address Line 2 City State / Province / Region ZIP / Postal Code

Home Number

Work Number Number

Cellphone Number

Patient Next Of Kin

Next of Kin Name

Next of Kin ID Number

Next of Kin Home Number

Next of Kin Work Number

Next of Kin Cell Number

Next Of Kin Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Relationship

Additional Contact Person

Contact Name

Phone

Patient Medical Aid Details

Medical Aid

Scheme Option

Medical Aid Number

Dependant Code

GAP Cover

Yes

Person responsible for account

Main member of medical aid

Name

Title Initials Full Names Surname

ID of main member

Enter Email Confirm Email

Home Tel

Work Phone

Cellphone No.

Fax No.

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Postal Address

Street/Postal Address Address Line 2 City State / Province / Region ZIP / Postal Code

Relationship

Self

Spouse

Child

Other

Employer's Details

(of Member/Person responsible for account)

Employer Name

Employer Tel

Address of employer

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code

Occupation

Details of accident (if applicable)

Type of accident

Motor Vehicle

Motor Cycle

Injured on duty

Domestic accident

Sport injury

Other

Details of how the injury was sustained