Pre-Admission Form

Fields marked with a * are required. Once submitted, please also email a copy of your Medical Aid Card to info@umhlanga-eye.co.za

Admitting Doctor*
listed alphabetically
Practice No.
Date of Procedure*
Main Member Name*
Main Member ID Number*
Medical Aid Name and Option*
Medical Aid Number*
Patient Name*
Patient ID Number*
Paitent Cell Number*
Patient Email Address*
Paitent Address
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Procedure*
Injection and Nappi Code
if applicable
ICD10 codes
Visual Acuity
Procedure Code
Consent*
- I consent to Umhlanga Eye Institute obtaining authorisation from my Medical Aid for the above procedure
Any other comments

Print Form

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Complete your details and send it through to our reception on:

Fax: 031 536 1802
or
Email: info@umhlanga-eye.co.za