Pre-Admission

Our Doctors

An entire floor of the hospital is dedicated to a Cardiac Centre of Excellence. In a highly sophisticated and hi-tech environment.

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Medical Specialities

An entire floor of the hospital is dedicated to a Cardiac Centre of Excellence. In a highly sophisticated and hi-tech environment.

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Centres of Excellence

Ethekwini Hospital & Heart Centre

	Pre-Admission Form
ID Number or Passport Number	Invalid Input
Title	Invalid Input
Surname (*)	Please type your full name.
Name	Invalid Input
Birth date	Invalid Input
Gender (*)	MaleFemale Invalid Input
Race	Asian Black Coloured White Other Invalid Input
Religion	I do wish to be visited by a religious leaderI do NOT wish to be visited by a religious leaderNo Preference Invalid Input
Language	Invalid Input
Home phone	Invalid Input
Work phone	Invalid Input
Cellular phone	Invalid Input
E-mail (*)	Invalid email address.
Occupation	Invalid Input
Employer	Invalid Input

	Main Member of Medical Aid / Guarantor
ID Number or Passport Number	Invalid Input
Title	Invalid Input
Surname	Invalid Input
Name	Invalid Input
Birth Date	Invalid Input
Gender	Male Female Invalid Input
Race	Asian Black Coloured White Other Invalid Input
Religion	I do wish to be visited by a religious leaderI do NOT wish to be visited by a religious leaderNo Preference Invalid Input
Language	Invalid Input
Home Phone	Invalid Input
Work phone	Invalid Input
Cellular phone	Invalid Input
Email address	Invalid Input
Occupation	Invalid Input
Employer	Invalid Input

	Address Details
	Residential Address
Street Address 1	Invalid Input
Street Address 2	Invalid Input
Suburb	Invalid Input
Province	Invalid Input
Post Code	Invalid Input
Country	Invalid Input
What Country (If Other Selected)	Invalid Input

Street Address 1	Invalid Input
Street Address 2	Invalid Input
Suburb	Invalid Input
Province	Invalid Input
Post Code	Invalid Input
Country	Invalid Input
What Country (If Other Selected)	Invalid Input

	Admission Details
Admission date	Invalid Input
Date of surgery	Invalid Input
	Please supply correct codes as supplied by your doctor if possible
Diagnosis or ICD 10 code– text	Invalid Input
Description of procedure (CPT code)	Invalid Input
Medical Aid Authorisation number*	Invalid Input
Admission diagnosis	Invalid Input
is this procedure as a result of an injury	YesNo Invalid Input
If yes, how did you sustain the injury?	Invalid Input
Admitting doctor – text	Invalid Input
Who referred you?	Doctor Friends or familySelf Invalid Input
Doctors name	Invalid Input

	Family contacts / Next of kin
Title	Invalid Input
Surname	Invalid Input
Name	Invalid Input
Relationship to you	Invalid Input
Home Phone	Invalid Input
Work phone	Invalid Input
Cellular phone	Invalid Input
Email address	Invalid Input
	Residential Address
Street Address 1	Invalid Input
Street Address 2	Invalid Input
Suburb	Invalid Input
Province	Invalid Input
Post Code	Invalid Input
Country	Invalid Input
What Country (If Other Selected)	Invalid Input
	Postal Address copy
Street Address 1	Invalid Input
Street Address 2	Invalid Input
Suburb	Invalid Input
Province	Invalid Input
Post Code	Invalid Input
Country	Invalid Input
What Country (If Other Selected)	Invalid Input

	Other Contact
Title	Invalid Input
Surname	Invalid Input
Name	Invalid Input
Relationship to you	Invalid Input
Home Phone	Invalid Input
Work phone	Invalid Input
Cellular phone	Invalid Input
Email address	Invalid Input
	Residential Address
Street Address 1	Invalid Input
Street Address 2	Invalid Input
Suburb	Invalid Input
Province	Invalid Input
Post Code	Invalid Input
Country	Invalid Input
What Country (If Other Selected)	Invalid Input

	Medical Aid Scheme
Medical Aid Scheme	Invalid Input
Member number	Invalid Input
Dependant code	Invalid Input
Hospital Insurance plan type	Invalid Input
Policy number	Invalid Input
	No Medical Aid? Please contact the hospital to obtain estimated costs for your procedure. Payment is required before admission for Private Patients. Any additional costs are payable on discharge.
	Medical History
Do you have any allergies?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Are you currently taking medication?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Do you or other members of your family have any of the following?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Diabetes or other endocrine conditions?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Epilepsy	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Blood abnormalities	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Porphyria	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
	Do you have or have you had the following?
Adverse reaction to anaesthetic?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Asthma, bronchitis or other respiratory disease?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Cardiac problems?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
History of jaundice?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
High or low blood pressure?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Recent illness (eg. cold or flu)	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Digestive problems?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Skin wounds/sores/rashes/bruising?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Eye, ear, nose, throat or speech problems?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Musculo-skeletal or joint problems?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Neurological problems?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Cortisone treatment?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Previous anaesthetic or operations?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Do you smoke? (please indicate how many)	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Do you drink alcohol? (how many units per week)	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Are you pregnant?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Do you have dentures, crowns, contact lenses or other prosthetics?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
Have you had an X-Ray or ECG?	YesNoDon't know Invalid Input
If yes, please provide further information	Invalid Input
	Please read and understand the terms and conditions of submission (click here to read)
Have yead and understood the terms and conditions?	Invalid Input
	Invalid Input
Submit

Latest Arrivals

Ethekwini Hospital & Heart Centre

Physical Address	:11 Riverhorse Road, Riverhorse Valley Business Estate, Queen Nandi Drive, Durban, 4017
Telephone	:+27 31 581 2400
Fax	:+27 31 581 2699
Email	: info@ehhc.co.za

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