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