Personal Information

Surname (required)

Name (required)

Initials (required)

Title (required)

Gender (required)
MaleFemale

Identity Number (required)

Date of Birth (required)

Other Names (required)

Mobile Number (required)

Work Number (required)

Home Number (required)

Email Address (required)

Residential Address (required)

Suburb (required)

Province (required)

Code (required)

Postal Address (required)

Province (required)

Code (required)

Marital Status (required)

Religion (required)

Dietary Preference (required)

Guarantor Information

Surname (required)

Name (required)

Initials (required)

Title (required)

Gender (required)
MaleFemale

Relationship to Patient (required)

Email (required)

Other Names (required)

Mobile Number (required)

Work Number (required)

Home Number (required)

Emergency Contact Physical Address (required)

Suburb (required)

Province (required)

Code (required)

Medical Aid Information

Medical Aid Name (required)

Plan Type (required)

Member Number (required)

Authorisation Number (required)

Main Member Name (required)

Main Member Surname (required)

Title (required)

Initials (required)

Identity Number (required)

Gender (required)
MaleFemale

Department Code (required)

Date of Birth (required)

Clinical Information

Primary Reason for Seeing the Doctor (Complaints / Symptoms) (required)

Indicate Which Chronic Symptoms You Suffer From (required)
DiabetesAnemiaHypertensionPorphyriaCholesterolDepressionCardiacThyroid DisordersAsthmaEpilepsy

Are You On Any Anticoagulant Therapy (Warfarin, Disprin, Clexane) (required)
—Please choose an option—YesNo

Important Information

If you are a PRIVATE PATIENT, it is your responsibility to ensure that you contact the accounts department for a quotation prior to your admission, and MEDICAL AID patients need to obtain an authorisation prior to admission, any shortfalls or copayments will be your own liability, Your MEDICAL AID CARD AND ID DOCUMENT are pre-requisitites for admission otherwise you will be treated as a private patient. PRIVATE WARDS REQUESTS: This will remain your responsibility, and will be subject to availability.

I hereby declare that all information mentioned above, personal and clinical is correct and agree to the the terms and conditions mentioned above.

Date (required)