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REFERRAL & ADMISSION FORM

FOR COMPLETION BY DOCTOR

ADMITTED FROM:

INFECTION CONTROL

MRSA
CRE
SARS-COV-2
REASON FOR REFERRAL
ALLIED HEALTHCARE PROFESSIONAL
ADL
INTRAVENOUS TREATMENT
OXYGEN / NEBULIZATION
MOBILISATION
DOES THE PATIENT HAVE A:
IS THE PATIENT ON ANTICOAGULATION THERAPY
DIETARY
PLEASE HAND THIS FORM IN AT HOSPITAL ADMISSIONS 48 HRS BEFORE ADMISSION OR MAIL
TO: pre-auths@sensohealth.co.za BOTH THE ID DOCUMENT OF THE MAIN MEMBER AND PATIENT AS WELL AS THE MEDICAL AID CARD MUST BE PROVIDED UPON ADMISSION PRIVATE AND MEDICAL AID PATIENTS WITH A CO-PAYMENT MUST PAY A DEPOSIT UPON ADMISSION. PLEASE CONTACT THE ACCOUNTS DEPARTMENT

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