New Patient Form

- Step 1 of 7

PATIENT DETAILS

Patient Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Date *

Date of Birth *

Sex *

Email *

Cell Phone Number

Home Phone Number

Work Phone

Can We Leave a Message?

Home
Cell
Work

Please tick all that apply

Patient Current or Previous Occupation *

Marital Status *

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Next Of Kin Details

Emergency Contact's Name *

First

Last

Contact Number *

Address

Address Line 1

City

State / Province / Region

Relation to Patient *

Current Healthcare Provider

May We Send Them Information? *

Healthcare Provider Contact Information

Please add a contact phone number and email address

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Medical Aid Details

Do you have a Medical Aid?

Medical Aid Name

Option

Medical Aid Number *

Main Member ID *

Main Member Name *

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Person Responsible For Account

Fill in if different from above.

Name *

First

Last

Address

Address Line 1

City

State / Province / Region

Postal Code

Phone Number

Email *

ID Number

Occupation

Employer

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Patient Consent

Tick the box to indicate that you understand

Costs

We charge a levy of R350.00 per medical aid. We work at medical aid rates for some procedures. However, for certain procedures there will be no co-payments. These co-payments will be communicated with the patient or the person in charge of the account. The cost of consultation is R700 for cash payments and is non-refundable.

Routine Procedures

Scaling - Professional cleaning where plaque is removed. Some bleeding be noticed. Furthermore, sensitivity after cleaning is uncommon.
Fillings - A procedure to close cavities in teeth. Please note post-operative sensitivity may be noticed. Fillings especially large fillings may dislodge.

Social Media

I agree for my non-clinical photos. To be distributed on social media. Once distributed these photos can be removed at anytime with my request.

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Health Questionnaire

Do you suffer from any of the following?

Sinus Problem *

Provide Detail

Diabetes *

Provide Detail

Porphrya *

Provide Detail

Kidney Disease *

Provide Detail

Epilepsy *

Provide Detail

Heart Problems *

Provide Detail

High Blood Pressure *

Provide Detail

Low Blood Pressure *

Provide Detail

Asthma *

Provide Detail

Tuberculosis *

Provide Detail

HIV *

Provide Detail

Any Allergies *

Provide Detail

Are you pregnant *

Provide Detail

Other *

Provide Detail

Are you taking any medication?

Please specify

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Dental Questionaire

Fill in if different from above.

What brigs you here today? *

When was your last dental visit? *

Do you have any crowns/bridges/implants/dentures? *

Do you have any existing fillings? *

Any extracted teeth? *

How was your previous dental experience? *

How Did You Hear About Us?

Internet/Search Engine
Friend Referal
Social Media
Referral
TV/Radio
Third-Party Review
Other

If other, please specify

Account Terms And Conditions

Private Patients

I agree that the information provided is correct and that should any information change, I should inform the receptionist.
I agree that I will settle my account immediately after service is rendered.
I agree that I will be held liable for any interest on my overdue account.
I agree that my account will be handed over if there is any outstanding amount and any changes associated with collection will on my behalf.

Medical Aid Patients
I agree that the information provided is correct and that should any information change, I should inform the receptionist.
I agree that I will be held liable for any interest on my overdue account.
I agree that my account will be handed over if there is any outstanding amount and any changes associated with collection will on my behalf.
I agree that I will settle any partly or unpaid account I agree that my account will be handed over if there is any outstanding amount and any changes associated with collection will on my behalf.
I agree that should my medical aid not pay out within 60 days that I will be held liable for settlement.I agree that my account will be handed over if there is any outstanding amount and any changes associated with collection will on my behalf.
I agree that it is my responsibility to understand the nature of my plan and procedures covered.I agree that my account will be handed over if there is any outstanding amount and any changes associated with collection will on my behalf.
I agree that it is m responsibility to make sure to see that my scheme account is submitted and settled.

Signature (Patient) *

By signing I agree to the terms and conditions stated above.

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Email *

New Patient Form

PATIENT DETAILS

Next Of Kin Details

Medical Aid Details

Person Responsible For Account

Patient Consent

Health Questionnaire

Dental Questionaire

Account Terms And Conditions

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