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BUiTEPASIENTE EN/OF ONGEVALLE AFD. • OUTPATIENT AND/OR CASUALTY DEPT.

i s

•.......a . : . . . . . . . . fcAAL • HOSPITAL PAS I £ NT • PATIENT No.':3 3 2 4 G

j j k lla j S t S :

deroe?Occupation

r> o........... ...

G e io o le d a tu m Date of birth........ • I l M

N sam van persoon veranfwoordelik vir befaling van rekening .. Name of person responsible for payment of account............... ...I

Sy/Haaradres ♦ His/Kefaddress....

Naarn van werkgewer ♦ Kerne of employer—

es van v/erkoewer • Address of em ployer....’..l (+

Naarn van siekefonds Name of sick fund........

•Jaariikse gesinsi.nkomsle » Annual fam!|” 1 U'rt alfe bro.nne . - c " “ i-; ...

Sr? ■ ' S.T N'd. .

Bro-odwinr.er • i i ■ :••• j-r ~v ..

Vrou • Wife. ..... • R

Ander afhanklikes • 0 :nc; O r.': nda.nts..:

Totaal • Total R

!

'Geta! persons in cesi.n (brooddinner ingesluit)Number of personl in household (including breadw inner).

Weld ouderdomme van afhanklikesState aces o! dependants............................................................

Rede vir afhanklikheidReason for dependence..............................................................

v ( V.inderjariges van 16 jaar en ouer wa! selfonderhouoer.d is, moe! urtgeslurt word) S- V ^^V .ir.o r children of 16 years and oldeder who a-e self-suppoi:ng must be excluded)

It:

Datum van ongeluk'oesering Dale of accident/injury.............................y T .Persoon v>at beseerde i.ngebring he* Person who brought intheTnjured........

Sy/Haar adres iHis/Her address.

Sy/Haar ha.ndtekening H.;s/Ker signature

W as besserde: .W as injured:

Piek Tyd Place............................................................................................. Time .

Klacte Complain!

Huidige siekte

• • • • m « a .

1S L E G S VIR AFSKEURSTROKIES

F O = ̂ ^••\T E R F 0 |LS ONLY

T.P .H . 253

; Daium Dale -. Betalihjs • Payn 1

'• • :-v V’-v-r r~ 1Beialings • Paymenls Be’.alinjs • Payments '

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5 -• S 3 ■ . • w •- HP'.'- ‘ 'J i . .O' CD C-- is ..................

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nekenines • Accounts

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T O : T H E S U P E R I N T E N D E N TN A T A L S P R U I T H O S P I T A L

: " C O N S E N T _TQ_ S U P P L Y C O N F I D E N T I A L M E D I C A L R EPORT'

Y i • • v- r ; . ; •. # :

N A M E O F P A T I E N T :

H O S P I T A L R E F E R E N C E N O : (ft j c]

D A T E O F T R E A T M E N T

I> the u n d e r s i g n e d ,

j iv. cfot<e

do h e r e b y r e q u e s t a n d a u t h o r i z e y o u to g i v e a m e d i c a l r e p o r t o n t he i n j u r i e s s u s t a i n e d and t r e a t m e n t r e c e i v e d b y me, and to E u p p l y c o p i e s o f all m e d i c a l r e c o r d s , x - r a y s and r e c o r d s of any o t h e r f o r m o f t r e a t m e n t to : —

TH E S T A T E A T T O R N E Y 8 8 8 R O Y A L S T . M A R Y’S B U I L D I N G

8 5 E L O F F S T R E E T P R I V A T E B A G X? J O H A N N E S B U R G

as a m a t t e r o f u r g e n c y .

I h a v e f u l l y c o n s i d e r e d t h e i rr.p 1 i c at i ons of my a c t i o n s and a u t h o r i z e y o u to g i v e all m y m e d i c a l r e c o r d s to my leoal r e p r e s e n t a t i v e s or a n y p r i v a t e d o c t o r th e y m a y a d v i s e me to see

S I G N E D at t h i s the Q ^ ' d a y of 1992.

A S W I T N E S S E S r -

S I G N A T U R E O F C O N S E N T E E O R R I G H T H A N D T H U M B

s

Collection Number: AK2702 Goldstone Commission of Enquiry into PHOLA PARK Records 1992-1993 PUBLISHER: Publisher:-Historical Papers, University of the Witwatersrand Location:-Johannesburg ©2012

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