Online Pre-Admission – Advanced Health

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Day Hospitals
Find a Doctor
Surgical Procedures
Private Funding
Patient Information
- Online Pre-Admission
About Us
Contact Us

Online Pre-Admission

What to bring

When you visit one of our hospitals you will need to bring the following:

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

Panorama Important Notice – All Advanced Panorama patients will receive an SMS or an email with your Pre-Admission instructions.

Pre-Admission Form

Online pre-admission form for members

"*" indicates required fields

Step 1 of 8 - Admission Details

12%

Admission Details

Day Hospital*

Doctor (De La Vie)*

Doctor (Durbanville)*

Doctor (East Rand)*

Doctor (Knysna)*

Doctor (Groenkloof)*

Doctor (Harbour Bay)*

Doctor (Medgate)*

Doctor (Panorama)*

Doctor (Worcester)*

Referring Doctor*

Diagnosis*

Procedure*

Date of Procedure*

DD slash MM slash YYYY

Authorisation Code (Members Only)

Diagnosis Codes / ICD 10 Codes*

Primary CPT Doctors Code*

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 Country

Postal Address*

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

Home Number

Work Number

Cell Number*

Email*

Patient Next of Kin

Next of Kin Name*

Next of Kin ID Number*

Relationship*

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

Additional Contact Person

Contact Name*

Phone Number*

Patient Medical Aid Details

Medical Aid

Scheme Option

Medical Aid Number

Dependant Code

GAP Cover*

Yes

No

Person Responsible for Account

Name*

Title Initials Full Names Surname

ID of Main Member*

Email*

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 Country

Postal Address*

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

Relationship*

Self

Spouse

Child

Other

Employer's Details

Employer of the Member/Person Responsible for Account

Employer Name*

Employer Tel*

Occupation*

Address of Employer*

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

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

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Day Hospitals

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info@advancedhealth.co.za
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