11.22
STATIONERY
FORMS
PRE-ADMISSION FORM
40
People often find forms difficult to fill in. We have
made our forms as friendly as possible to improve
the experience of the user.
5
5
PRE-ADMISSION FORM/VOOROPNAMEVORM
SIZE
1
FOR COMPLETION BY THE DOCTOR/MOET DEUR DOKTER INGEVUL WORD
CPT CODE/KODE
A4 (210 x 297mm).
Annotated example shown at 60% of actual size.
Dimensions are in millimetres. Magenta numbering
relates to the specification text below.
ADMITTING DOCTOR/OPNAMEGENEESHEER
ADMISSION DATE/OPNAMEDATUM DD/MM/YY
TIME/TYD
:
ICD CODE/KODE
DATE OF OPERATION/OPERASIEDATUM DD/MM/YY
CO-MORBIDITY/KO-MORBIDEIT
LOGO
DIAGNOSIS AND PROCEDURE/DIAGNOSE EN PROSEDURE
SADA CODE/KODE
Logo colour version 1 (see pages 3.7 and 3.8).
Size at 40mm.
FOR COMPLETION BY PATIENT (PLEASE PRINT)/ MOET DEUR PASIËNT INGEVUL WORD (DRUKSKRIF ASSEBLIEF
1
COLOUR
1
FAMILY DOCTOR/HUISDOKTER
Two-colour in Mediclinic Blue and black. Highlight
text in Mediclinic Blue. Other text in 85% black.
2
REFERRING DOCTOR/VERWYSENDE GENEESHEER
FORM PRESENTATION
TITLE/TITEL DR/MR/MRS/MS/MISS
GREY PANELS
Grey panels in a 10% tint of black with rounded
corners are used to help the user navigate
through the information.
D.O.B/GEBOORTEDATUM DD/MM/YY
TEL
CELL/SEL
PRE-ADMISSION FORM/VOOROPNAMEVORM
PRE-ADMISSION FORM/VOOROPNAMEVORM
CPT CODE/KODE
ADMITTING DOCTOR/OPNAMEGENEESHEER
BUSINESS NAME/BESIGHEIDSNAAM
EMPLOYER/WERKGEWER
ADMISSION DATE/OPNAMEDATUM DD/MM/YY
TIME/TYD
:
TEL
BUSINESS ADDRESS/WERKADRES
ICD CODE/KODE
HOME ADDRESS/WOONADRES
DATE OF OPERATION/OPERASIEDATUM DD/MM/YY
CO-MORBIDITY/KO-MORBIDEIT
SADA CODE/KODE
POSTAL ADDRESS/POSADRES
CODE/KODE
NEXT-OF-KIN/NAASBESTAANDE
TEL
To improve the patient experience further,
the pre-admission form could be kept private
and confidential by handing it to the recipient
in a closed clipboard. The clipboard should be
in Mediclinic Blue.
PEN WITH ANTIBACTERIAL GRIP
PEN
FOR COMPLETION BY THE DOCTOR/MOET DEUR DOKTER INGEVUL WORD
DIAGNOSIS AND PROCEDURE/DIAGNOSE EN PROSEDURE
CLIPBOARD
GENDER/GESLAG M/M F/V
TRIPLE SIDED FOLDER OUTSIDE
FULL NAME/VOORNAAM
CELL/SEL
RELATIONSHIP/VERWANTSKAP
FOR COMPLETION BY PATIENT (PLEASE PRINT)/ MOET DEUR PASIËNT INGEVUL WORD (DRUKSKRIF ASSEBLIEF
OTHER CONTACT PERSON/ANDER KONTAKTPERSOON
FAMILY DOCTOR/HUISDOKTER
TEL
CELL/SEL
RELATIONSHIP/VERWANTSKAP
PLEASE OBTAIN THE FOLLOWING INFORMATION FROM YOUR MEDICAL AID 72 HOURS BEFORE ADMISSION.
VERKRY ASSEBLIEF DIE VOLGENDE INLIGTING 72 UUR VOOR OPNAME BY U MEDIESE FONDS
REFERRING DOCTOR/VERWYSENDE GENEESHEER
MEDICAL AID NAME/NAAM VAN MEDIESE FONDS
TITLE/TITEL DR/MR/MRS/MS/MISS
D.O.B/GEBOORTEDATUM DD/MM/YY
GENDER/GESLAG M/M F/V
*CONTACT PERSON/*KONTAK PERSOON
THIS PEN HAS AN ANTIBACTERIAL GRIP
2
FULL NAME/VOORNAAM
TEL
*OPTION
OPSIE
CELL/SEL
HOME ADDRESS/WOONADRES
MEDICAL AID NO.
MEDIESE FONDSNOMMER
*AUTHORISATION NO.
MAGTIGINGSNR
*CONFIRMATION NO.
BEVESTINGINGSNR
DEPENDANT CODE
AFHANKLIKE KODE
POSTAL ADDRESS/POSADRES
*MEDICAL AID APPROVED LOS/MEDIES SKEMA