11.1
STATIONERY
OVERVIEW
EXAMPLES
PRE-ADMISSION FORM/VOOROPNAMEVORM
FOR COMPLETION BY THE DOCTOR/MOET DEUR DOKTER INGEVUL WORD
CPT CODE/KODE
ADMITTING DOCTOR/OPNAMEGENEESHEER
MEDI-CLINIC OFFICES, STRAND ROAD
STELLENBOSCH 7600
SOUTH AFRICA
Address line one
Address line two
Address line three
Address line four
Address line five
Address line six
ADMISSION DATE/OPNAMEDATUM DD/MM/YY
PO BOX 456, STELLENBOSCH 7599
TIME/TYD
:
ICD CODE/KODE
DATE OF OPERATION/OPERASIEDATUM DD/MM/YY
T +27 21 809 6500
F +27 21 809 6756
CO-MORBIDITY/KO-MORBIDEIT
www.mediclinic.com
DIAGNOSIS AND PROCEDURE/DIAGNOSE EN PROSEDURE
SADA CODE/KODE
FOR COMPLETION BY PATIENT (PLEASE PRINT)/ MOET DEUR PASIËNT INGEVUL WORD (DRUKSKRIF ASSEBLIEF
3rd December 2010
FAMILY DOCTOR/HUISDOKTER
REFERRING DOCTOR/VERWYSENDE GENEESHEER
Dear lorem ipsum,
TITLE/TITEL DR/MR/MRS/MS/MISS
Morbi sapien massa, luctus rutrum convallis id, rutrum eu nulla. Morbi commodo
tortor at arcu aliquet id pretium erat viverra. Duis a leo pretium metus egestas
rhoncus et nec leo. Donec vehicula sodales molestie. Suspendisse nec augue
magna. Praesent fermentum velit non dui bibendum dictum. Etiam consequat,
sem non semper ultrices.
Felis dui rutrum massa, auctor ullamcorper velit diam eu tortor. Cras cursus
pharetra elementum. Etiam facilisis viverra iaculis. Duis at dolor sed neque
venenatis egestas. Sed sit amet lacus nisi. Suspendisse sed arcu nunc. In pellen
tesque vulputate sapien, in vehicula mauris rutrum in. Duis gravida velit vel sapien
ullamcorper a sodales ipsum tristique. Duis sollicitudin luctus nibh at pharetra.
Morbi sapien massa, luctus rutrum at arcu aliquet id pretium erat viverra. Duis
a leo pretium metus egestas rhoncus et nec leo.
Donec vehicula sodales molestie. Suspendisse nec augue magna. Praesent
fermentum velit non dui bibendum dictum. Etiam consequat, sem non semper
ultrices, felis dui rutrum massa, auctor ullamcorper velit diam eu tortor. Cras cursus
pharetra elementum. Etiam facilisis viverra iaculis. Duis at dolor sed neque venen
atis egestas. Sed sit amet lacus nisi. Suspendisse sed arcu nunc. In pellentesque
vulputate sapien, in vehicula mauris rutrum in. Duis gravida velit vel sapien ullam
corper a sodales ipsum tristique. Duis sollicitudin luctus nibh at pharetra. Suspend
isse nec augue magna. Praesent fermentum velit non dui bibendum dictum. Etiam
consequat, sem non semper, felis dui rutrum massa, auctor ullamcorper velit diam
eu tortor. Cras cursus pharetra elementum. Etiam facilisis viverra iaculis. Duis at
dolor sed neque venenatis egestas.
D.O.B/GEBOORTEDATUM DD/MM/YY
GENDER/GESLAG M/M F/V
FULL NAME/VOORNAAM
TEL
JULIEN A. BURO
HEAD OF MARKETING
CELL/SEL
HOME ADDRESS/WOONADRES
POSTAL ADDRESS/POSADRES
CODE/KODE
CODE/KODE
SEEFELDSTRASSE 214
CH-8008 ZÜRICH
TITLE LINE ONE
TITLE LINE TWO
T +41 44 388 75 15
F +41 44 388 85 72
M +41 79 403 03 68
[email protected]
www.mediclinic.com
E-MAIL/E-POS
WITH
COMPLIMENTS
Sed sit amet lacus nisi. Suspendisse sed arcu nunc. In pellentesque vulputate
sapien, in vehicula mauris rutrum in. Duis gravida velit vel sapien ullamcorper
sodales ipsum tristique. Duis sollicitudin luctus nibh at pharetra.
MEDI-CLINIC OFFICES, STRAND ROAD
STELLENBOSCH 7600
SOUTH AFRICA
PO BOX 456, STELLENBOSCH 7599
T +27 21 809 6500
F +27 21 809 6756
Materials such as CD labels and
covers, and folders are available
in several styles to suit different
budgets and audiences.
ID NO./NR
LANGUAGE/TAAL E/A
PATIENT WEIGHT/PASIËNT GEWIG
PATIENT HEIGHT/PASIËNT LENGTE
KG
M
OCCUPATION/BEROEP
RELIGION/KERKVERBAND
ACCOMODATION CHOICE/VERBLYFKEUSE
GENERAL WARD/ALGEMENE SAAL
SEMI-PRIVATE/SEMI-PRIVAAT*
PRIVATE/PRIVAAT*
www.mediclinic.com
*WARDS ARE SUBJECT TO AVAILABILITY AND CARRY A DAILY SURCHARGE. CONTACT HOSPITAL BEDBOOKINGS FOR DETAILS.
*SALE IS ONDERHEWIG AAN BESKIKBAARHEID. ‘N BYBETALING MOET BETAAL WORD. KONTAK DIE HOHOSPITAAL SE
BEDBESREKINGAFDELING VIR BESONDERHEDE.
1/2
Suspendisse nec augue,
Mediclinic
Marc Marty
DIRECTORS
NAME LASTNAME, NAME LASTNAME,
NAME LASTNAME, NAME LASTNAME, NAME LASTNAME
REG. NO. 0000/000000/00
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