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.
For Online Pre-admissions please fill out the two compulsory online forms below:

1. Patient Questionnaire
2. Pre-Admission Form (Medical Aid or Private)

If you prefer to download, print, and fill in the forms manually – please click on the buttons below.
Email the completed form to admissions@centuriondayhospital.co.za and cc ellen@centuriondayhospital.co.za

    This information is crucial to the Anaesthetist

    Do you suffer from any of the following?
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    YesNo
    Pre-Admission Information
    Doctor’s Information
    Patient Details
    Person responsible for account
    Employer’s Detail (Person responsible for payment of account)
    Person to contact in case of emergency/Next of Kin (not someone that lives with you)
    Person responsible for account
    I hereby confirm all details supplied are correct and true
    Doctor’s Information
    Patient Details
    Details- Main member of Medical aid
    Employer’s Detail (Main member)
    Person to contact in case of emergency/Next of Kin (not someone that lives with you)
    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