Online Admissions

Surname

Initials

Title

Language

Afrikaans English

Full Names

Gender

Female Male

ID Number

Tel

Date of Birth

Home Address

Street Code

Occupation

Employer

Business Address

Business Tel

Contact Person

Relationship

Contact Cell

Other Contact Person

Other Contact Cell

Medical Aid

Plan

Medical Aid Number

Authorization

Main Member

Surname

Initials

Title

Patient Dependant Code

Relationship to Patient

ID Number

Member Telephone Number

Member Postal Address

Postal Code

Details of the person responsible for payment.

Surname

Initials

Title

Relationship to Patient

Telephone Number

Cell Number

ID Number

Home Address

Street Code

Postal Address

Postal Code

Method of Communication

SMS EMAIL TELEPHONE OTHER

Please Note: Both the ID document of the Main member and patient as well as medical aid card must be provided upon admission.