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 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, ______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, 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, 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 ______

TO BE COMPLETED BY RADIOGRAPHER EXAMINATION C O NSUMABLES ______

Theatre : Time In______Time out______Screening______minutes Dose______

Images : Prints CD's Film Received by______Signature______DOC ......

RAD......