Empowering you
with hope


Pre-Admission Form

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.

Contact us on 051 – 446 3242, during office hours, to confirm your admission or should you have any other queries.

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