Jul 12

Application for Admission

Application for Admission Form

Details of Patient:

Surname:     ____________________________________

Full Names: ____________________________________

Id Number:  ____________________________________

Birthdate:  _______________________ age:__________

Diagnosis:________________________  Docter:__________________

Allergy:  ___________________________________________________

Surgery: ___________________________________________________

Chronic Illness: ______________________________________

Chronic Medication:YES/NO     Smoker:YES/NO     Alcohol use:YES/NO




Contact Details of Person Responsible for account:


Surname:  __________________________________________


Full Names:  ________________________________________


ID Number:   ________________________________________



Tel:  ________________________________


Email address: ______________________________________


Physical Address: ______________________________________________




_____________________________Code: ____________


Postal Address:     ______________________________________________


_____________________________Code: ____________

Medical Aid: _________________________________________


Number: _________________________________________

Plan: _________________________________________



Details of Relatives:


Name: ______________________Surname:___________________Tel:___________________

Name: ______________________Surname:___________________Tel:___________________


Name: ______________________Surname:___________________Tel:___________________


Terms and Conditions

– I hereby certify that I am, the signatory here below, is responsible for the account of this resident/patient.

– I undertake to pay all legal costs relating to the recovery of outstanding money.

– La Reynette Centre do not refund any money being paid in advance, unless otherwise specified in writing by L.R.C. management. No refunds will be made to patients/residents after 10 days stay when admitted on a monthly contract basis, specified in writing.

– All clothing, equipment, etcetera not collected within 30 day’s of the patient/residents discharge or death, shall be distributed to community projects.

– 30 Days calendar notice is required for residents/patients who live in on a monthly basis.

– Copy of identification of resident/patient must accompany this admission form.

– Copy of medical aid of resident/patient to accompany this admission form.

– All the medical information about the resident/patient is correct and treatment done accordingly. L.R.C. will not be held responsible for any wrong information that may lead to wrongful medical treatment.


The Abbreviation LRC. stands for La Reynette Centre





I, ________________________________________  hereby formally


apply for the admission of (patient name)  ____________________________________   at  La Reynette Centre.


I, _________________________________________ the person


responsible for all payments, ID No __________________________


hereby agree and understand all the rules and regulations as set out


above on this day: ___________________  20______


at:________________________ and agree to adhere to all the regulations.


I also hereby confirm that I have read, understand and accept the rules of Protocol as per


two page addendum attached ________________________________________.

Signature of person responsible for payments




La Reynette Centre Protocol

*all medical and residential bills are payable by the signatory on the admission form.

*LRC do not take responsibility for the loss of any valuable items not handed in for safe keeping.

*All clothing, apparatus and personal belongings must be clearly marked.

*Diabetic patients/residents are responsible for supplying their own sugar.

*LRC supply three home cooked meals daily as well as two tea time snacks.

*Monthly patients/residents are subject to give us 30 day notice of the intention to leave the facility.

*LRC do not keep any money for patients as all their needs are catered for.

*Smokers are only allowed to smoke outside at clearly designated areas.

*Patients/residents/families are free to make use of the swimming pool with supervision for children under 16 years.

*Families are free to have a braai with patients/residents on weekends.

*Patients/residents are responsible for their own nappies. We do supply nappies at market related rates.

*The patient/residents must supply LRC a copy of the script for any medication to be administered. Without such script no medication will be administered whatsoever.

*We advise all patients to be seen by our house doctors. This gives us access to their expert advice in all medical emergencies regarding the patient.

*Visitation to outside doctors and specialists or hospitals are to the account of the family and/or patient/resident, except where alternative arrangements have been made.

*24 Hour nursing care, bed baths, a roll in shower, assisted baths and all hygiene processes are all part of our service.

*Sick bay available.

*Visiting hours are between 10h00-12h00, 14h00 -16h00 and 17h00-20h00.

*Please do not park in the street as far as possible. Secure parking is available on request.





*Ask about our service providers who visit our patients at our care center in the capacity of: Physiotherapy, dentistry (false teeth), hair dressing (cut & blow), podiatry, pastoral, wound care sisters, occupational therapy, etc.


*In the event of a patient not being able to take direction/guidance for their own

Safety’s sake, we remain the right to ask the family to sign an indemnity form.


*Patients are liable for their monthly account even if they were transferred to a hospital   for intensive care or medical procedures. All monthly residents/patients are subject to a 30 day notice period in writing. Verbal notice will not be accepted.


*We might be required to pass on some of the patient’s information on to the following businesses/institutions to properly care for them as the need arises.

– Robert Broom Medical Centre – General


– Ronel Venter Physiotherapy Inc.

– Dental Connection

– Sacks Pharmacy

– Netcare Pharmacy

– Netcare Hospital KDP

– Eco-Med, Oyzone or Vital Aire

If any of these service suppliers are not be used and personal information (such as medical aid details) are not to be forwarded to them, please provide us with a notice thereof in writing.

RE: POPI Law on Personal Information act.