Patient Information
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   Surname *
 		    Title *
 		    Initials *
 
   First Name *
 
   Home Address *
 
   Code *
 
  Home Tel *
 
  Cell No *
 
  Work Tel
   ID No *
 
   Postal Address *
 
   Code
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   Gender *
 
   Diabetic  |
   Allergy *
 
  Next Of Kin
  Name *
 
  Relation *
 
  Phone No *
 
  Name
  Relation
  Phone
Main Member Information
   Surname *
 		    Title *
 		   Initials *
 
   First Name *
 
   Postal Address *
 
   Code
   Occupation
   Employer
   Work Address
   Relation to Patiënt
  Home Tel *
 
  Cell No *
 
  Work Tel
   ID No *
 
   Medical Aid *
 
   Medical Aid no *
 
   Authorisation no
   Referring Doctor
   Attending Doctor *
 
Facilities Services Support Group Pre Admission Form
Bloemcare is a 87-bed private psychiatric hospital that provides mental health services to patients who are 12 years and older. A special adolescent u
Services: 24 hours nursing care Group therapy programme Occupational therapists Physiotherapists Biokineticist Dietici
The Befrienders Support groups available for victims of: abuse, depression, crime, domestic violence
For your convienience we have posted our admission form online
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