Mediclinic Constantiaberg 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.

For completion by the doctor

CPT codeICD codeSADA codeAdmitting doctorDate of admissionTime of admissionDate of operationCo-morbidityDiagnosis and procedurePatient weight (kg)Patient height (m)

Patient details

Doctor who referred youFamily doctorSurname *InitialsTitleLanguage (English / Afrikaans / other)Full name *Telephone *Date of birthGenderRSA / Namibia ID numberPassport number if other citizenshipHome addressPostal codeEmail *Accommodation choice (general / semi-private / private)OccupationEmployerBusiness addressBusiness telephone

Contact people

Contact personContact cellphoneRelationship to patientOther contact personOther contact cellphoneOther contact relationship

Main member of medical aid

SurnameInitialsTitleMedical aid namePlan / optionMedical aid numberAuthorisation numberDependant codeRelationship to patientID numberTelephonePostal addressPostal codeEmail

Person responsible for payment

SurnameInitialsTitleRelationship to patientTelephoneCellphoneID numberCitizenship (RSA / Namibia / other)Home addressHome postal codePostal addressPostal codeEmailOccupationEmployerEmployer telephoneBusiness addressBusiness postal codePreferred method of communication (SMS / email / telephone / other)Visit from religious representative? (yes / no)Religion

Signatures

Patient typed signature (full name) *Patient signature date *Patient signature timePatient signature placeGuardian / guarantor name, if applicableGuardian / guarantor typed signature, if applicableGuardian / guarantor signature dateGuardian / guarantor signature timeGuardian / guarantor signature placeReceptionist name (hospital use only)Receptionist typed signature (hospital use only)Receptionist date (hospital use only)Receptionist time (hospital use only)Receptionist place (hospital use only)

Mediclinic admission conditions

Obtain medical aid authorisation at least 48 hours before admission. The original form requires submission at reception at least 48 hours before admission and a medical aid card and ID on admission. Private patients may need to pay a deposit.

Read the full admission and payment conditions below before signing. The hospital remains responsible for confirming its own admission requirements.

Mediclinic conditions of admission and payment, including English and Afrikaans terms and signature lines

Mediclinic Constantiaberg Patient Information Form

Mediclinic admission conditions

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