Busamed Modderfontein Private Hospital

Pre-Admissions Form

Modderfontein Private Hospital is dedicated to excellence in patient care. By filling out your pre-admissions form, you provide us with the essential details needed to customise our services and enhance your healthcare journey, ensuring a supportive and caring environment from the start.

Patient Information

Name(Required)

First Last

Identity Number(Required)

Email Address

Home Telephone Number

Cell Phone Number(Required)

Physical Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Postal Address

Same as previous

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Company/Employer Information

Company/Employer's Name

Occupation

Company Address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Work Telephone Number

Medical Aid Details

Medical Aid Name

Plan

Membership Number

Dependant Code of Patient

The Patient is the Main Member(Required)

Yes

Main Member's Details

Name

First Last

Identity Number

Home Telephone Number

Cell Phone Number

Physical Address

Same as patient's physical address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Doctor's Details

Admitting Doctor(Required)

This field is hidden when viewing the form

Admitting Doctor

Please select your admitting doctor from this list. If you cannot find your doctor on this list please select, 'other' and fill out your doctor's name in the next step.

This field is hidden when viewing the form

Admitting Doctor's Name

Referring Doctor

Family/House Doctor

Next of Kin

Name(Required)

First Last

Relationship(Required)

Contact Number(Required)

Physical Address

Same as patient's physical address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Add a second contact?

Name(Required)

First Last

Relationship(Required)

Contact Number(Required)

Physical Address

Same as patient's physical address

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Admission Details

Admission Date

Procedure / Diagnosis

ICD 10 Codes

Procedure Codes

Authorisation Number

Co-payment / Deductible

Supporting Documents

Copy of ID

Max. file size: 2 MB.

Medical Aid Card

Max. file size: 2 MB.

Doctor's Referral Letter

Max. file size: 2 MB.

Consent

Disclaimer

I hereby confirm that the information completed on this form is correct.

Documents required on admission:

Original medical aid card/membership certificate.
ID document of patient and main member.

Private Patients

A deposit is required on admission as per the estimated quotation provided.

Medical Aid Patients

Please consult with your medical aid to obtain an authorisation number prior to admission.
Any short falls not covered by your medical aid will be for you own account.

Private and Semi-private Wards

Available on request should the rooms be available. An extra cost may apply.

Name

This field is for validation purposes and should be left unchanged.

Pre-Admissions Form

Patient Information

Company/Employer Information

Medical Aid Details

Main Member's Details

Doctor's Details

Next of Kin

Admission Details

Supporting Documents

Consent

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