Pre Admission Form * indicates a required field. Some fields may become required based on your selection. Please use ALL CAPS when completing this form Please DO NOT use any punctuation when completing this form Patient Details Title * Choose... Please select a valid title. Initials * Valid initials required. First Names * Valid first name is required. Last Name * Valid last name is required. ID or Passport Number * ID number is required. Nationality * Choose... Please select a valid title. Date of Birth * Please select a valid date of birth. Home Language * Choose... Please select a valid home language. Sex * Choose... Valid sex required. Religion * Choose... Valid religion required. List of Allergies Please enter a valid list of allergies. Contact Details Mobile/Cell Number * Please enter your phone number. Email Address Please enter your email address. Residential Address Line One * Please enter your address. Line Two Please enter your address. Suburb * Please enter your suburb. City * Please enter your city. Postal Code * Postal code required. Postal address is the same as my residential address Postal Address Line One * Please enter your address. Line Two Please enter your address. Suburb * Please enter your suburb. City * Please enter your city. Postal Code * Postal code required. Next of Kin Full Name and Surname * Please provide a name for the next of kin. Mobile/Cell Number Please enter a phone number for the next of kin. Email Address Please enter an email address for the next of kin. Next of Kin Address Line One Please enter your address. Line Two Please enter your address. Suburb Please enter your suburb. City Please enter your city. Postal Code Postal code required. Medical Aid Details If you do not have a medical aid, please select "Private Patients" for your scheme name and "Private" for the scheme option. Medical Aid Name * Choose... If you do not see your medical aid, start typing to search through all available medical aids. Please select a valid medical aid. Medical Aid Option * Choose... Please select a valid medical aid option. Medical Aid Member Number * Please enter your medical aid number. Dependant Code Please enter your medical aid dependant code. Main Medical Aid Member Details Patient is main member Title * Choose... Please select a valid title. Initials * Valid initials required. First Names * Valid first name is required. Last Name * Valid last name is required. ID or Passport Number * ID number is required. Relationship to Patient * Choose... Please select a valid relationship. Mobile/Cell Number * Please enter your phone number. Email Address * Please enter your email address. Main Member Residential Address Main member has same residential address as me Line One * Please enter your address. Line Two Please enter your address. Suburb * Please enter your suburb. City * Please enter your city. Postal Code * Postal code required. Main Member Postal Address Main member has same postal address as me Line One * Please enter your address. Line Two Please enter your address. Suburb * Please enter your suburb. City * Please enter your city. Postal Code * Postal code required. Pre Admission Details Patient Type * Choose... Please select a valid patient type. Medical Aid Authorisation Number Disclaimer I, the main member/dependant of the abovementioned medical aid, hereby accept full responsibility for the payment of any account that may arise from the treatment of the abovementioned patient. I will follow up with my medical aid to ensure payment and undertake to pay any amounts outstanding not paid by my medical aid. Should the account be handed over, I am aware I will be liable for all legal costs. Any changes in details I have provided here are my own responsibility to amend. I agree to the above disclaimer Please agree to the disclaimer. Privacy Declaration I hereby consent to the processing of my personal data for the selected purposes, and agree that KZN Day Clinic may collect, store, process and use the personal data I have provided. My data will only be processed for any purpose beyond those specified if required by law. I can withdraw my consent to the processing of my data at any time by contacting KZN Day Clinic. I agree to the above declaration of consent to the use of my data Please agree to the privacy declaration. Submit
