Request Forms

ASCOT PARK HOSPITAL 3 Ascot Street JACKPERSAD & PARTNERS INC. GREYVILLE 031 365 2135 a/h: 031 314 3000 SPECIALIST DIAGNOSTIC RADIOLOGISTS Practice No. 3804917 inf [email protected] www.jackpersad.co.za LIFE CHATSMED. GARDEN HOSP. 80 Woodhurst Drive, Woodhurst CHATSWORTH THIS SECTION MUST BE COMPLETED BY REQUESTING MEDICAL PRACTIONER 031 402 9280 a/h: 031 459 8000 PATIENT NAME_____________________________________________________________________D.O.B_____/_____/_____ CITY HOSPITAL MEDICAL AID WCA PRIVATE ICD 10 CODE____________________________ 83 Ismail C Meer Street DURBAN DATE OF INJURY_________/________/________ EVENT NO____________________________________ 031 309 8465 a/h: 031 314 3000 CLINICAL INFORMATION / DIAGNOSIS________________________________________________________________________ DAYMED PRIVATE HOSP ________________________________________________________________________________________________________ 595 Chota Motala Rd. Raisethorpe ______________________________________________________________________________________________________ PIETERMARITZBURG 087 501 0043 ______________________________________________________________________________________________________ a/h 033 387 1100 ______________________________________________________________________________________________________ DURDOC HOSPITAL 460 Anton Lembede Street, ______________________________________________________________________________________________________ DURBAN 031 305 9559 EXAMINATION/S REQUESTED____________________________________________________________________________ a/h: 031 314 3000 ______________________________________________________________________________________________________ EDEN GARDENS _______________________________________________________________________________________________________ PRIVATE HOSPITAL Archie Gumede Rd, PIETERMARITZBURG ________________________________________________________________________________________________________ 087 501 0042 A/H 033 815 4600 PR AC TIT ION ER 'S NA ME _____________________________ PRACTITIONER'S SIGNATURE_______________________ LENMED eTHEKWINI HOSPITAL PRACTICE NO.___________________ TELEPHONE:________________________ EMAIL________________________________ & HEART CENTRE 11 Riverhorse Road,, NURSE / RECEPTIONIST NAME_______________________ SIGNATURE______________________________________ Nandi Drive, DURBAN 031 569 6645 / 6 a/h: 031 581 2400 PATIENT'S DETAILS BUSAMED HILLCREST Full Name _________________________________ PRIVATE HOSPITAL 471 Kassier Road, ASSAGAY ID No. _____________________________________ 031 768 1800 Postal Address ______________________________ a/h: 031 768 8000 ______________________________Code________ ISIPINGO HOSPITAL 162 Phila Ndwandwe Road Residential Address __________________________ ISIPINGO RAIL PLACE STICKER HERE 031 910 7220 ___________________________________________ a/h: 031 913 7000 ______________________________Code_________ LENMED SHIFA PRIVATE HOSPITAL Tel. Work ________________Home______________ 482 Randles Road, OVERPORT 087 501 0041 Dependent Code _____________________________ a/h: 031 240 5000 Cell _______________________________________ LIFE MT.EDGECOMBE HOSP Relationship to member _______________________ Female: pregnant? YES NO UNSURE 602 Redberry Drive, PHOENIX 031 502 9500 E-Mail _____________________________________ LAST MENSTRUAL PERIOD____________________ a/h: 031 537 4000 MEDICLINIC HOWICK RADIOLOGIST CONSULT / RECOMMENDATION HOSPITAL 107 Main Street, HOWICK _________________________________________________________________________________________________________ 033 330 5962 a/h: 033 330 2456 ____________________________________________________________________________________________________________ MIDLANDS MED. CENTRE SIGNATURE_____________________________________________ DATE________________________________________________ 162/6 Masukwana Street PIETERMARITZBURG THIS SECTION MUST BE COMPLETED BY THE PATIENT IN FULL Yes No 033 392 4780 a/h:033 341 5000 1. I have been examined by the above requesting Practitioner ....................................................................... 2. I agree to have the requested examination................................................................................................... MEDICLINIC PMB HOSPITAL 3. I accept personal responsibility for payment for requested examination 90 Payne St. within 30 days - irrespective of any third party............................................................................................... PIETERMARITZBURG 033 392 4720 4. I certify that my personal details above / on hospital sticker are correct....................................................... a/h: 033 845 3700 5. I give permission to divulge ICD 10 code Radiology report to the requesting... MEDICLINIC VICTORIA HOSP. Practitioner / Third Party funder..................................................................................................................... 35 High Street, TONGAAT 6 I give access of my digital images on PACS/CD to my requesting Practitioner........................................... 032 438 3200 7. I accept that in the event of non payment in 30 days,interest & Debt collection charges may be charged. a/h: 032 945 8200 Signed at_____________________________________ on this___________ day of _________________________ 20_________ WESTRIDGE MED. CENTRE 95 King Cetshwayo Highway, Patient’s/ Members’s/Guardian Signature_________________________Witness 1______________Witness _______________ WESTRIDGE, DURBAN 031 273 1050 APPOINTMENT DATE _____________________TIME_________ ARRIVAL DATE___________________ TIME______________ Patient I D ______________________________ Case I D _________________________________ Proc I D___________________________________ CONSENT FOR PROCEDURE I hereby give consent for the injection or administration of any drug or contrast medium and use of any other item or procedure, which may be deemed necessary for the performance of my examination namely_____________________________________________ _____________________________________________________________________________________________________________ ALLERGIES___________________________________________________________________________________________________ SIGNATURE ____________________________________WITNESS______________________________ DATE______/______/______ PERSON RESPONSIBLE FOR PAYMENT Title____Initial_______Surname___________________________First Name______________________________ ID No.________________________ Medical Aid Name______________________________________________ Medical Aid Number__________________________________________ Plan Option___________________________________________________ Depedent Code_____________________________________________ Postal Address________________________________________________ Residential Address__________________________________________ ____________________________________________Code __________ ___________________________________________Code___________ Telephone Work_______________________Cell__________________________________ Residence ______________________________________ Member's e-mail_______________________________________________ Employer___________________________________________________ Work Address_________________________________________________ Occupation__________________________Employee No____________ ______________________________________________Code__________ Fax________________________Contact Person__________________ Relative / Friends Address_____________________________________________________________________________Code __________________ FOR OFFICE USE: MEDICAL AID AUTHORISATION Patients full name______________________________________________ Tariff Code__________________________________________________ Date of Birth__________________________________________________ Practice No_________________________________________________ Referring Doctor________________________________________________ Hospital Authorisation No______________________________________ Procedure Date________________________________________________ Reference No._______________________________________________ ICD 10 code___________________________________________________ M.A Authorised by____________________________________________ Cost of scan___________________________________________________ Length of stay updated Yes No Authorisation date______________________________________________ Invoice Number______________________________________________ M.A. Authorisation No___________________________________________ Medical Secretary: Authorisation _______________________________ AUTHORISATION FOLLOW UP Date Time Reception Comments Contact Person Reference No _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________ _________________________________________________________________________________________________________________________

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