Kilnerpark Day Hospital
THE MOST AFFORDABLE OPTION – FAST | FRIENDLY | PROFESSIONAL
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Online Admission
PATIENT DETAILS
Full Name
*
Last name
*
ID Number
*
Age
*
Email
*
Address
*
Cellphone Number
*
Phone - Home
Phone - Work
Medical Aid Dependant Code (eg: 01)
DETAILS OF FRIEND OR FAMILY MEMBER (not residing at the same address)
Initials
*
Last name
*
Address
*
Phone
*
Relation
*
DETAILS OF PERSON RESPONSIBLE FOR ACCOUNT
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
*
APPOINTMENT & BED RESERVATION MADE BY
Dentist/Doctor
*
Date of Procedure
*
Time of Procedure
*
Type of Procedure
*
Medical Aid Authorisation Number
*
Submit Admission Form