Online Pre-admissions

This information is crucial to the Anaesthetist

Name

ID Number

Age

Weight

Do you suffer from any of the following?

Pre-Admission Information

Please choose Medical aid / Private:

Doctor’s Information

Date of Procedure:

Patient Details

Date of Birth:

Sex:MaleFemale

Preferred Language:EnglishAfrikaans

Person responsible for account

Title:MrMrsMissDr

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)

Title:MrMrsMissDr

Person responsible for account

I hereby confirm all details supplied are correct and true

Doctor’s Information

Date of Procedure:

Patient Details

Date of Birth:

Sex:MaleFemale

Dependent Code:

Preferred Language:EnglishAfrikaans

Details- Main member of Medical aid

Title:MrMrsMissDr

Employer’s Detail (Main member)

Person to contact in case of emergency/Next of Kin (not someone that lives with you)

Title:MrMrsMissDr

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

Patient Space | Online Pre-admissions

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

This information is crucial to the Anaesthetist

Do you suffer from any of the following?

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

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

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Patient Space | Online Pre-admissions