Impilo Patient Information Form

Complete the fields below and send the form to Cape Town Vascular. Fields marked * are required. For hospital admission, the hospital may still request its own original form or signature.

Hospital use only

DoctorSurgery booked timeTime of arrivalWard detailsBed detailsPre-admission number

Patient personal information

Identifier typeIdentifier numberSurname *Name *InitialsOther namesKnown asTitleGenderDate of birthMobile number *Work numberHome numberPreferred method of contactReceive marketing? (yes / no)Receive statements? (yes / no)Email address *Residential addressResidential suburbResidential cityResidential postal codePostal addressPostal suburbPostal cityPostal codeMarital statusDietary preferenceReligionCongregationMinister

Emergency contact

SurnameNameRelationship to patientMobile numberWork numberHome numberAddressSuburbCityPostal code

Alternative contact (not living at the same address)

SurnameNameRelationship to patientMobile numberWork numberHome numberAddressSuburbCityPostal code

Medical aid information

Medical aid schemePlanMember numberAuthorisation numberPrincipal member surnamePrincipal member namePrincipal member initialsPrincipal member titlePrincipal member SA ID numberPrincipal member date of birthPrincipal member genderDependant code

Hospital visit information

Admission dateSurgery booked dateSurgery timeAdmitting doctorReferring doctorAlternate doctorGeneral GPICD code / diagnosisCPT code / procedure

Guarantor information

Identifier typeIdentifier numberSurnameNameInitialsOther namesKnown asTitleGenderDate of birthMobile numberWork numberHome numberPreferred method of contactReceive marketing? (yes / no)Receive statements? (yes / no)Email addressResidential addressResidential suburbResidential cityResidential postal codePostal addressPostal suburbPostal cityPostal code

Clinical information

Brief description of symptoms or complaintsIf diabetic, control used (tablets / insulin / diet / none)Chronic conditions: hypertension, multiple sclerosis, cholesterol, emphysema, asthma, epilepsy, thyroid disorder, lupus, depression, heart failure, porphyria, other

Declaration

Patient typed signature (full name) *Date of signature *

Important hospital notes

The original Impilo sheet asks that pre-admission information be faxed or handed in as soon as possible. For hospital assistance, contact reception on 021 670 4000. The sheet lists fax 021 670 4090, email debbie.williams@lifehealthcare.co.za and practice number 5808480.

Private patients need a prepayment; contact the accounts department for an estimated cost.
Medical aid patients should obtain pre-authorisation. Short payments remain for the patient account.
Bring your medical aid card and ID book on admission or the hospital may treat you as a private patient.
Private or semi-private wards are subject to availability and may require payment of the private ward rate on admission.

Impilo Patient Information Form

Important hospital notes

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