PATIENT INFORMATION FORM

A. PERSONAL DETAILS

Name: Surname:
Nationality: Age:
Gender: Male: Female: Country code + Home Telephone number:

Physical Address: Country Code + Work Telephone number:

Country Code + Cellphone number:
Passport Number (please fax copy): E-Mail address:

B. DETAILS OF CURRENT TREATING DOCTOR'S

Name of family doctor: Country Code + Telephone number:
Address: Country Code + Fax umber:
E-mail address:
Name of referring doctor: Country code + Telephone number:
Address: Country code + Fax number:
E-mail address:

C. MEDICAL HISTORY

Diabetic of any endocrine disease If yes, provide details
Yes No
Hypertension / High Blood Pressure If yes, provide details
Yes No
Epilepsy or any other neurological disorders If yes, provide details
Yes No
Asthma or any other pulmonary/lung disorder If yes, provide details
Yes No
Infectious diseases e.g. TB, Yellow fever, Malaria If yes, provide details
Yes No
Skin disease If yes, provide details
Yes No
Hematological / Blood Disorders If yes, provide details
Yes No
Psychiatric disorders If yes, provide details
Yes No
Any previous surgical procedures or operations If yes, provide details
Yes No
Any food or drug allergies? If so, what are they?
Yes No
Current medication, including oral contraceptives & non prescription drugs. If so, what are they?
Yes No
Do you smoke or take alcohol? If so, what is the quantity per day?
Yes No
Female patients only:
Are you pregnant? 		If so, how far are you?
Yes No

D. MEDICAL INSURANCE / MEDICAL AID

Name of Medical Insurance Company: Country code + Telephone number:
Contact person: Address:

E. PLEASE GIVE A BRIEF DESCRIPTION OF YOUR MEDICAL PROBLEM AND THE MEDICAL/ SURGICAL TREATMENT RECEIVED TO DATE

F. SERVICE REQUIRED (Please tick and give description)

Medical Treatment Surgical Operations
Cosmetic Surgery and Treatment (please provide photographs) Medical Check-up
Transportation
Accommodation
Please tick the type of accommodation you require:
3 star hotel
4 star hotel
5 star hotel
Guest House
Self catering executive apartment

G. FRIENDS AND FAMILY

In case of an emergency contact name Country code + Telephone number:
Relationship: Address:
Your next of Kin: Country code + Telephone number:
Relationship Address:
Will you be bringing accompanying family members? If yes, how many
Yes No
Name: Relationship:

H. ARE AS OF INTEREST IN SOUTH AFRICA (Optional - please tick)

Cape Town & Cape Areas
Kruger National Park & Safaris
Golf Safaris
Wine Tours / Estates
Heritage sites
Sun City / Lost City
Casinos & Resorts
Spas & Health Resorts
What are your hobbies & interests? What sport or exercise do you participate in?

Have you traveled in the last 3 months? If yes where did you travel to?
Yes No


What is your expected date of arrival in South Africa? Do you have any dietary requirements? If yes, specify.

J. REFERRAL DOCTOR

Name of referral doctor following departure: Country code + Telephone number:
Address:

Security Code:
Retype Code: