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012 663 2010
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info@centuriondayhospital.co.za
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Office Hours: Monday to Friday 06:00 - 16:30 | Saturday 06:00-13:00
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Patient Space | Online Pre-admissions

Online Pre-admissions​

Please bring along the following documents:

  • Main member’s ID book.
  • Patient’s ID book.
  • Medical aid scheme card.
  • Doctor’s letter of referral.
  • Medical aid scheme authorisation number (we can assist with this if necessary).

The admission clerk will:

  • Help you complete all the relevant documents.
  • Assist you in obtaining authorisation from your medical aid scheme.
  • Collect the co-payments (if necessary) or private patient upfront deposit.
  • Explain the admission process.

Pre-admissions​ Form

For Online Pre-admissions, please fill out the form below.
If you need any assistance, get in touch with our admissions team at admissions@centuriondayhospital.co.za

All items marked with a * are required fields.

    1

    Patient Information

    2

    Responsible for Account

    3

    Medical Aid

    4

    Clinical Info & Submit

    Patient Information

    Surname*:

    Full Names*:

    Initials*:

    Title*:

    Email*:

    Gender*:

    Date of Birth*:

    ID Number*:

    Mobile Number*:

    Work Number*:

    Home Number*:

    Residential Address*:

    City*:

    Postal Code*:

    Date of Procedure*:

    Treating Doctor*:

    1

    Patient Information

    2

    Responsible for Account

    3

    Medical Aid

    4

    Clinical Info & Submit

    Medical Aid or Private Patient: Person Responsible for Account

    ID Number*:

    Full Names*:

    Surname*:

    Mobile Number*:

    Work Number*:

    Home Number:

    Residential/Postal Address of Person Responsible for Account*:

    Employer Address of Person Responsible for Account*:

    Employer Telephone Number*:

    Emergency Contact: (Person to be contacted in case of a medical emergency)

    Surname*:

    Name*:

    Mobile Number*:

    Relationship to patient*:

    1

    Patient Information

    2

    Responsible for Account

    3

    Medical Aid

    4

    Clinical Info & Submit

    Medical Aid Information (Please record your details as per medical aid card)

    Medical Aid Scheme*:

    Member Number*:

    Medical Aid Plan*:

    Surname*:

    Full Names*:

    Authorisation Number*:

    Title*:

    Initials*:

    Gender*:

    ID Number*:

    Dependant Code*:

    1

    Patient Information

    2

    Responsible for Account

    3

    Medical Aid

    4

    Clinical Info & Submit

    Patient Clinical Information

    Have you had major surgery recently, if yes, any problems?

    Weight*:

    Height*:

    List of current/chronic medication:

    Do you suffer from any chronic conditions/illness as listed below?

    (Please indicate with a Y for YES or N for NO)

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    YesNo

    Main member

    I give Centurion Day Hospital the authority to claim/submit the account on my behalf
    I hereby confirm all details supplied are correct and true