PREADMISSION ONLINE FORM - Johannesburg Surgical Hospital

Authorisation Number

Main Member initials

Main Member Gender

Male Female

Main Member Date of Birth

Main Member First Names

Main Member Mobile Number

Main Member Residential Address

Account Holder Title

Account Holder initials

Account Holder Gender

Male Female

Account Holder Date of Birth

Account Holder Email

Account Holder Surname

Account Holder First Names

Account Holder Mobile Number

Account Holder Nationality

Account Holder Home Language

Account Holder Occupation

Account Holder Work Tel Number

Account Holder Residential Address

Account Holder Postal Address

Relationship to Patient

ICD10/diagnosis code

A breif description of symptoms & complaints

Chronic Conditions: Please indicate if the patient has any of the following

If you selected "Allergies" or "Other" please nspecify below

PATIENTS PLEASE TAKE NOTE OF THE FOLLOWING

1. PRIVATE PATIENTS - A prepayment is required on/before admission from patients not covered by medical aid. It is suggested that private patients contact the accounts department prior to admission to establish the estimated hospital cost. 2. MEDICAL AID PATIENTS - Please consult with your medical aid prior to admission to obtain a pre-authorisation number. Any short payments by your medical aid will be on your own account. 3. MEDICAL AID CARD & ID - Must be produced on admission otherwise patient will be treated as private. 4. PRIVATE / SEMI PRIVATE WARDS - Medical aid patients requesting private wards wil be expected to pay the private ward rate on admission. Please note private wards are subject to availability. hereby declare that the information I have provided on this form is true & correct, & I agree to the terms & conditions.

pre-admission form

Navigation

24 Hours Emergency Number:

Navigation