PATIENT DETAILS

Title*

Surname*

Full Names*
Gender*
Employment Status*

ADDRESS

Home Address

Address*
City*
Postal Code*

CONTACT INFORMATION

Home* Number
Mobile Number*
Email*
Preferred Contact Method*


REFERRAL

Referred By*


PERSON RESPONSIBLE FOR ACCOUNT

How will you settle the account?

Medical Aid
Medical Aid Number
Main Member Name
Main Member ID Number


APPOINTMENT INFORMATION

Purpose of visit*

Dental EmergencyScale and polish (dental cleaning)Full check-­‐upCosmetic dentistry consultationOrthodontic consultationImplant consultation


PREVIOUS MEDICAL HISTORY

Have you had or have any of the following?

Previous orthodontic treatment braces or platesClicking, popping or discomfort in the jawAware of grinding or clenching of your teethSleep apneaDry mouthBad breathHistory of periodontal (gum) treatmentsProblems associated with previous dental treatmentSerious injury to your head
Serious injury to your mouthTeeth sensitive to hot cold or sweetHead, neck, jaw pain, or achesGastric refluxSnoringMouth breathingMouth ulcers or soresBulimiaSpeech problems

Do you smoke (including E-cigarettes)*


PRE-EXISTING CONDITIONS

Do you have any of these pre-existing conditions?

Rheumatic feverHIV/AidsKidney diseaseFrequent head achesPacemakerLow blood pressureHeart valve replacementJaundiceAsthmaCancerDiabetesTuberculosisVenereal diseaseAnemiaChemotherapyStrokeHepatitisBleeding disordersPsychiatric treatmentEpilepsyHigh blood pressureJoint replacementRadiotherapyChronic Sinusitis

Name of treating physician


Are you pregnant or breastfeeding?
Are you allergic to latex?*
Have you ever had a bad reaction to local anaesthetics?*

Please list any drug allergies*

Please list any medication you are currently taking at the moment*


GENERAL DENTAL INFORMATION

Last Visit To a Dentist*
Last Dental Cleaning*


DENTAL HABITS

How often do you brush your Teeth?*
How often do you floss?*


FEE STRUCTURE FOR THE PRACTICE

This practice is contracted out of medical aid and therefore does not claim from any medical aid. The patient is responsible for the full account, which has to be settled immediately after the appointment.

CONSENT FOR SERVICES AND UNDERTAKING TO PAY

As a condition of your treatment by this office, financial arrangements must be made in advance. This practice depends on the reimbursement from the patients for the costs incurred in their care and financial responsibility on the part of each patient must be determined before treatment. We are committed to your dental care being successful. Please understand that payment for your care is considered part of that care. Please read the following information carefully. We ask that you read the information, and agree to the information prior to any treatment.

• All emergency dental services, or any dental services performed without previous financial arrangements must be paid for in CASH at the time services are rendered.
• All patients must complete our patient information form before receiving treatment.
• No guarantees can be made about treatment outcomes, restoration longevity, or prognoses. I understand that any branch of medicine, including dentistry, can involve unanticipated results.
• Full payment is due at the time of service unless previous arrangements have been made.
• Patients who carry dental insurance understand that all dental services furnished are charged directly to the patient’s account. We will complete the patient’s insurance forms or assist in making collections from insurance companies and will credit any such collections to the patient's account. However, this dental office cannot render services on the assumption that our charges will be paid by an insurance company.
• Estimated co-pay and deductible is due at the time of service.
• We accept Cash, Visa Cards, MasterCard, American Express and Edcon credit cards.
• We offer an extended payment plan (First Health Finance) with prior credit approval.
• A service charge of 1% per month (12% per annum) on the unpaid balance will be charged on all accounts exceeding 60 days, unless previously written financial arrangements are satisfied.
• There will be a charge for appointments missed without 24 hours notice.

Please let us know if you have any questions or concerns regarding this information.

I understand and agree to the terms regarding payment.*
I agree that the information is correct, and that will make known any changes to the treating doctor.*

Comments or Questions

* Required