Patient Information Form

Visitors form

Full Patient Name: *

ID: *

Person responsible for account / Main member: *

Postal / Home Address: *

Tel. No (H):

(W)

Cell:

Email: *

Medical Aid Scheme: *

Number: *

Next of Kin: *

Tel: *

Reffered by:

Language Preference:

Afr

Eng

1. Allergic to penicillin or any other allergy: *

2. Excessive bleeding requiring special treatment: *

3. Please select

Heart Disease

Heart Murmur

High blood pressure

Stroke

Rheumatic fever

Covid-19

Diabetes

Tuberculosis

Hepatitis

Arthritis

Kidney disease

Gastric ulcer

4. Heart Surgery:

Bypass

Transplant

Replacements:

Knee

Hip

Shoulder

5. Any other serious illness *

6. Current Medication *

7. Women only: Are you pregnant?

Yes

No

POPI Act - I have read and agreed to the terms and conditions *

Yes

If you are human, leave this field blank.