PATIENT ADMISSION FORM CLARO CLINIC PATIENT INFORMATIONYOUR NAME(Required) Surname First Name Initials Title HOME ADDRESS(Required) Address Line 1 Address Line 2 Suburb/City Postal Code POSTAL ADDRESS Address Line 1 Address Line 2 Suburb/City Postal Code CELLPHONE(Required) HOME PHONEWORK PHONE EMAIL ADDRESS(Required) OCCUPATION BUSINESS/SCHOOL NAME BUSINESS/SCHOOL ADDRESS Address Line 1 Address Line 2 Suburb/City Postal Code DATE OF BIRTH(Required) YYYY dash MM dash DD AGE IDENTITY NUMBER(Required) LANGUAGEEnglishAfrikaansOtherGENDERMaleFemaleOtherNEXT OF KIN 1 Name Relationship Telephone NEXT OF KIN 2 Name Relationship Telephone MEMBER INFORMATIONPERSON RESPONSIBLE FOR ACCOUNTACCOUNT WILL BE PAID BY(Required)Medical AidPrivate PersonMEDICAL AID MEDICAL AID NUMBER AUTHORISATION NUMBER MAIN MEMBER RELATIONSHIP TO PATIENT CELLPHONEWORK PHONEHOME PHONEEMAIL ADDRESS IDENTITY NUMBER(Required) POSTAL ADDRESS Address Line 1 Address Line 2 Suburb/City Postal Code OCCUPATION BUSINESS NAME BUSINESS ADDRESS Address Line 1 Address Line 2 Suburb/City Postal Code STATISTICAL INFORMATIONORIGINAL REFERRER Name Details Telephone (e.g. company HR dept, media, school, church, friend)SECONDARY REFERRER Name Profession Telephone (e.g. Social Worker, Psychologist, GP, Psychiatrist)ATTENDING PROFESSIONAL Name Profession Telephone (e.g. Psychologist, GP, Psychiatrist, Dietician) REFERRING PROFESSIONAL Name Profession Telephone (e.g. Psychologist, GP, Psychiatrist, Dietician) CONSENT(Required) I hereby give my consent to the hospital to collect, use, and share my personal information for the explicit purpose of facilitating my in-hospital admission. I understand that the information shared may include, but is not limited to, my name, contact details, medical history, insurance information, and any other pertinent details necessary for admission and subsequent medical care.CAPTCHANameThis field is for validation purposes and should be left unchanged.
