Impilo Patient Information Form Page 2

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MEDICAL AID INFORMATION
(PLEASE RECORD DETAILS AS PER MEDICAL AID CARD)
MEDICAL AID SCHEME:
PLAN:
MEMBER NUMBER:
AUTHORISATION NUMBER:
PRINCIPAL MEMBER SURNAME:
NAME
DR / FR / MISS / MR / MRS / MS / PROF / REV
INITIALS:
TITLE :
SA ID NUMBER:
MALE / FEMALE
DATE OF BIRTH :
GENDER:
DEPENDANT CODE:
HOSPITAL VISIT INFORMATION
ADMISSION DATE:
SURGERY BOOKED DATE:
TIME:
ADMITTING DOCTOR:
REFERRING DOCTOR:
ALTERNATE DOCTOR:
GENERAL GP:
ICD CODE / DIAGNOSIS:
CPT CODE / PROCEDURE:
GUARANTOR INFORMATION
(PERSON RESPONSIBLE FOR THIS ACCOUNT)
ID / PASSPORT / PATIENT LIFE NUMBER/NOT ASSIGNED
IDENTIFIER NUMBER:
IDENTIFIER TYPE:
SURNAME:
NAME:
INITIALS:
OTHER NAMES:
KNOWN AS:
DR / FR / MISS / MR / MRS / MS / PROF / REV
MALE / FEMALE
DATE OF BIRTH :
TITLE :
GENDER:
MOBILE NUMBER:
WORK NUMBER:
HOME NUMBER:
MOBILE / WORK / HOME / EMAIL
Y / N
Y / N
PREFERRED METHOD OF CONTACT:
RECEIVE MARKETING?
RECEIVE STATEMENTS?
EMAIL ADDRESS:
RESIDENTIAL ADDRESS:
POSTAL ADDRESS:
SUBURB:
SUBURB:
CITY:
CODE:
CITY:
CODE:
CLINICAL INFORMATION
PLEASE PROVIDE A BRIEF DESCRIPTION OF THE SYMPTOMS/COMPLAINTS PRESENT WHEN VISITING THE DOCTOR:
SHOULD YOU BE SUFFERING FROM DIABETES MELLITUS PLEASE INDICATE WHICH FORM OF CONTROL IS BEING
TABLETS
INSULIN
DIET
NONE
PRACTICED?
DO YOU SUFFER FROM ANY OF THE FOLLOWING CHRONIC CONDITIONS/ILLNESS? (PLEASE INDICATE BELOW)
HYPERTENSION
MULTIPLE SCLEROSIS
CHOLESTEROL
EMPHYSEMA
ASTHMA
EPILEPSY
THYROID DISORDER
LUPUS
DEPRESSION
HEART FAILURE
PORPHYRIA
OTHER:
PATIENTS PLEASE TAKE NOTE OF THE FOLLOWING:
1.
PRIVATE PATIENTS - A prepayment is required on hospitalisation from patients not covered by medical aid. It is suggested that private patients
contact the accounts department prior to admission to establish the estimated hospital cost.
2.
MEDICAL AID PATIENTS – Please consult with your medical aid prior to admission obtaining pre-authorisation if necessary. Any short payments
by your medical aid will be for your own account.
3.
MEDICAL AID CARD AND ID BOOK – Must be produced on admission otherwise patient will be treated as private.
4.
PRIVATE/SEMI PRIVATE WARDS – Medical aid patients requesting private wards will be expected to pay the private ward rate on admission.
Please note private wards are subject to availability.
I ___________________________________________________________________________ hereby declare that the information I have provided is
true and correct and agree to the terms and conditions as set out above.
Patient Signature ______________________________________________
Date of Signature _______________________________________
PSM-FORM-ADM/001.5
Revision 0 – May 2009
Page 1 of 2

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