Kilnerpark Day Hospital

THE MOST AFFORDABLE OPTION – FAST | FRIENDLY | PROFESSIONAL

Online Admission

Full Name*

Last name*

ID Number*

Age*

Email*

Address*

Cellphone Number*

Phone - Home

Phone - Work

Medical Aid Dependant Code (eg: 01)

Initials*

Last name*

Address*

Phone*

Relation*

Full Names*

Last name*

Postal Address:*

Postal Code*

Employer*

Occupation*

Cellphone Number*

Phone - Home

Phone - Work

Medical Aid*

Medical Aid Plan*

Medical Aid Number*

Main Member ID Number*

Dentist/Doctor*

Date of Procedure*

Time of Procedure*

Type of Procedure*

Medical Aid Authorisation Number*