Pre-admission Registration

Patient Information

This is the person going for the elective procedure.

ID / Passport Number*

Marital Status*

Married Single Widow(er) Divorced

Do you belong to a Medical Aid?*

Yes No

Medical Aid Details

Start typing your medical aid below and then select it from the available list.

Patient Dependent Code*

Guarantor / Main Member

This is the person responsible for the account.

If you are on a medical aid, the guarantor is the main member of the medical aid.

Is the patient the guarantor?*

Yes No

Main Member Dependant Code*

ID/ Passport Number*

Marital Status*

Married Single Window(er) Divorced

Patient Postal Address

Guarantor Contact Details

Postal Address Line 2*

Postal Address Line 3*

Patient Employer Details

Type in the patient's employer details below.

Guarantor's Employer Details

Type in the guarantor's employer details below.

Employment Status*

Employed Self Employed Retired Not Employed

Employer Company Name*

Postal Address Line 2*

Postal Address Line 3*

Next Of Kin Details

Next of kin details of the guarantor.

Contact Phone Number*

All information submitted will be keot confidential and will only be used for the pre-admission process.

EDGE PATIENT & GUARANTOR REGISTRATION