Please complete in the form below to begin the registration process.
* Required Fields
Patient Info
Title *
Please Select
Initials *
First Names *
Surname *
ID Number
Date of Birth *
Sex *
Select Gender
Male
Female
Other
Email Address *
Cell Number
Home Language *
Please Select
Please list any allergies you have *
Religion *
Please Select
Nationality *
Please Select
Please list any specific dietary requirements you have *
Residential Address
Address
Suburb
City
Province
Country
Postal code
Postal Address
Same as Residential Address
Line 1
Line 2
Line 3
Line 4
Postal Code
Next of Kin
Name
Cell Number
Do you have a Medical Aid?
Yes*
No*
Medical Aid Details
Medical Aid *
Please Select
Plan *
Please Select
Medical Aid Number
Dependant Code
Dependant Code
00
01
02
03
04
05
06
07
08
09
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
Are you the Main Member?
Yes
No
Main Member Title
Please Select
Main Member Initials
Main Member First Names
Main Member Surname
Main Member ID Number
Main Member Cell Number
Main Member Email
Relationship *
Please Select...
Self
Spouse
Child
Other
Main Member Address
Line 1
Line 2
Line 3
Line 4
Postal Code
Main Member Postal Address
Line 1
Line 2
Line 3
Line 4
Postal Code
Pre Admission Details
Patient Type *
Day Patient
Authorization Number
Which Doctor is perfoming your procedure? *
Please Select
Select Your Procedure
Please Select
When is your Pocedure?
Submit
Edge Day Hospital Pre-admission
×
Thank you for registering.
Your Pre-Admission Number is:
This will also be sent to you via email.
(Please check your Junk Mail as well)