Secure Pre-Admission

Online Admission

Complete the Roman Catholic Hospital admission information before arrival. Access is password protected. Please call Reception or the Emergency Unit to obtain the current password.

Reception / Switchboard+264 61 270 2444 Emergency Unit+264 81 270 2143

Before you begin

Have the patient ID or passport ready.
Medical aid members should have membership and authorization details.
Accident cases may require a police report or employer documents.
Pre-admission forms should reach Reception at least 48 hours before admission.

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Protected Access

Enter the admission password

Call Reception or the Emergency Unit for the current password.

Admission Details

Clinical and admission information

Admitting Doctor Referring Doctor Diagnosis and Procedure Date of Admission Time of Admission

Section A

To be completed by the patient

Patient Surname First Name(s) Title Birth Date ID / Passport Number Citizenship Sex Marital Status Language(s) Church Residential Address PO Box Number Home Telephone Cell Number Business / Employer Employer Telephone Department Business Address Emergency Contact Emergency Contact Number Relationship Other Contact Person Other Contact Number Relationship

Theatre & Cathlab Pre-Admission Information booklet received Private patient

Section B

Medical aid information

Medical Aid Medical Aid Number Scheme / Option Authorization Number

Please bring:

Medical aid membership card and patient ID card or passport. Private patients must bring an ID/passport and make the required payment upon admission.

Section C

Account holder information

Surname First Name(s) Title Birth Date ID Number Passport Number Citizenship Residential Address PO Box Number Email Address Cell Number Business / Employer Employer Telephone Department Business Address

Account responsibility

The account holder accepts responsibility for payment, irrespective of medical aid, benefit scheme or insurer membership.
Hospital accommodation and treatment are subject to prescribed charges and conditions.
Outstanding accounts may be subject to recovery action and related legal or collection costs.
By signing, the account holder confirms acceptance of the hospital’s terms and conditions.

Sections D & E

Indemnity, consent and signatures

Indemnity

I acknowledge the hospital’s indemnity terms, including responsibility for personal valuables brought onto hospital premises, except where claims arise from gross negligence or wilful wrongful conduct.

Consent

I consent to general admission at Roman Catholic Hospital, its rules and policies, and to the necessary sharing of personal information with relevant third parties involved in admission, treatment and payment.

I have read and accept the account responsibility terms. I have read and accept the indemnity. I consent to admission and necessary information sharing. I authorize release of information to the medical aid fund, managed healthcare organization and their agents where required.

Patient / Account Holder Full Name Date Signed Signing on behalf of patient? Name Relationship to Patient

Typing your full name records an electronic acknowledgement for this pre-admission draft. Reception may still require a handwritten signature on arrival.

Release of Information

Accident or injury information

Not related to an accident or injury Accident or injury related

Final Step

Review and prepare your form

Important:

Review the information carefully, then submit it securely to the hospital. You may also print or save a copy for your records.

Optional supporting documents:

You may attach an ID/passport copy, medical aid card, doctor letter, police report or employer documents. Maximum 10 MB per file.

ID / Passport or Medical Aid DocumentAdditional Supporting Document