Bloemcare | Psychiatric Clinic with Adolecent Unit

In order to make your admission to Bloemcare as hassle-free as possible, the pre-admission form can be completed on-line or faxed to Bloemcare at 051 – 446 4469.

Patient Information

Title

Initials

First Name

Last Name

Religion

Gender

Diabetic

Allergy

Home Address

Street

Suburb

Town

Code

Contact Information

Home Telephone

Cell Number

Work Telephone

I.D. Number

Postal Address

Same As Home Address

Street | PO Box

Suburb

Town

Code

Next of Kin (1)

Name

Relation

Cell Number

Next of Kin (2)

Name

Relation

Cell Number

Main Member Information

Title

Initials

First Name

Last Name

Occupation

Employer

Relation to Patient

Postal Address

Street | PO Box

Suburb

Town

Code

Contact Information

E-mail

Cell Number

Work Telephone

I.D. Number

Work Address

Same As Postal Address

Street

Suburb

Town

Code

Medical Aid Information

Medical Aid

Medical Aid No.

Authorisation No.

Referring Doctor

Attending Doctor

Admissions

Pre-Admission Form

Patient Information

Home Address

Contact Information

Postal Address

Next of Kin (1)

Next of Kin (2)

Main Member Information

Postal Address

Contact Information

Work Address

Medical Aid Information