Details of patient

Surname

Full names

Title

Mr Mrs Miss Dr

ID Number

Employer

Work tel number

Details of main member

Surname

Full names

Title

Mr Mrs Miss Dr

ID Number

Employer

Work tel number

Postal address

Physical address

Tel number home

Tel number work

Cell number

Email address

Next of kin

Relationship

Their contact number

Details of medical aid

Name of medical aid

Option or plan

Membership number

Patient dependent no.

Authorisation no.

Admission Details

Admission date

Attending Doctor

Confirmation of Informed Consent

A. Adult Patient

Name

Healthcare practitioners name

Date of Procedure

My medical practitioner has fully explained to me, all aspects pertaining to my surgical procedure

I acknowledge and understand that all Medical Practitioners furnishing services to myself / the patient, including Auxiliary Personnel, Radiologists, Anaesthetists and the like, are independent contractors and are not employees or agents of the Medical Forum Theatre and that Medical Forum Theatre is in no way liable in respect of their treatment or services:

B. Minor Patient (under the age of 18 years old)

In the case of a minor/ incapacitated adult patient, consent must be provided by the parent or legal guardian

Name

Healthcare practitioners name

Date of Procedure

My medical practitioner has fully explained to me, all aspects pertaining to my surgical procedure

I acknowledge and understand that all Medical Practitioners furnishing services to myself / the patient, including Auxiliary Personnel, Radiologists, Anaesthetists and the like, are independent contractors and are not employees or agents of the Medical Forum Theatre and that Medical Forum Theatre is in no way liable in respect of their treatment or services:

Attachments

ID Document

Medical Aid Card

The above details are complete and correct