Home
About Us
Facilities & Services
Admission Procedure
Find a Physician
Employment Portal
Latest News
Contact us
Admission Form
Online Admission Form
Person Responsible for Paying Account or Medical Aid Main Member
Surname
Full Names
Marital Status
Postal Address
Code
Work
Home
Cell Nr
I.D Nr
Occupation
Employer
Work Address
Medical Aid
Membership Nr
Option
Dependant Nr
Date Joined
Authorization nr
E-mail
Next of Kin
Surname
Relationship
Address
Home
Work
Contact Person
Surname
Relationship
Address
Home
Work
Patient Information
Surname
Full Names
Residential
Code
I.D Nr
Gender
Language
Cell nr
Work
Religion
Relationship
Date of Birth
Admission Details
GP
Admitting Dr.
Practice no
Operation Date
Diagnosis & Procedure
Procedure Code
ICD 10 Code
Upload your medical aid card, doctor's letter, ID, etc here
Verification
Please enter any two digits
*
Example: 12
This box is for spam protection -
please leave it blank
:
Download Admission Form
