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Locations
The Sanctuary – Somerset West
Majik Forest – Bellville
Die Boord – Stellenbosch
Contact Us
Home
About Us
Services
General Practitioner
Dermatology
Advanced Mole Mapping & Skin Screening
Gynaecology
Paediatrics
Psychiatry
Out of Hospital Infusion Centre
Locations
The Sanctuary – Somerset West
Majik Forest – Bellville
Die Boord – Stellenbosch
Contact Us
Book a Consultation
Dr E Scott INC | West Med Medical Centre Sanctuary
(HCP) Medical Practitioner Out of Hospital Infusion referral & Authorisation Request
Date
Are you a Healthcare Practitioner
Yes
No
Patient Details
Surname
Full Names
Identity No / Passport
Date of Birth
Address
Co-morbidities/Risk Factors
Gestational Age
Body Weight
Gender
Male
Female
Authorisation Number
E-mail
Mobile
Work Tel
Referring Doctor Practice Details
Referring Doctor
Practice No.
Practice Email
Infusion Treatment Requested
Infusion Therapy Drug
Dosage
Duration
Prior Treatment Including Oral
Motivation for Treatment
Clinical Diagnosis
Latest Blood Results
Prescription
ICD 10 Codes
ICD-10 Code
Motivational ICD-10 Code
Diagnosis & Motivation
Medical Scheme
Medical Scheme Membership No.
Option
Dependant code - patient
How long has the patient been on this plan type/scheme
More than 6 months
More than 12 months
Date of Birth
I hereby refer the above-named patient to West Med Medical Centre – Dr E Scott Inc, for the administration of out-of-hospital infusion therapy, as clinically indicated. I request that West Med Medical Centre liaise directly with the patient’s medical aid to obtain pre-authorisation for both the medication and the infusion procedure. I confirm the following: The prescribed infusion medication must be procured directly by West Med to ensure eligibility for medical aid benefits. Only medications with a registered brand name, valid NAPPI code, and reference number will qualify for medical aid reimbursement. A comprehensive clinical report outlining the infusion details, patient response, and any relevant findings will be provided to me, the referring practitioner, to support ongoing continuity of care. Please contact me should any further information be required.
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