SANDTON: 011 784 7408  |  SPRINGS PRACTICE: 011 815 6951  |  SPRINGS MALL: 011 812 0024  |  MIDRAND: 010 442 3323
DURBAN: 031 780 1408  |  CENTURION: 012 643 0089

Patient Information

    We Wish To Extend To You a Warm Welcome

    This specialized field of Dentistry involves:

    Biological Principles -
    Health first
    concept
    Prevention of the breakdown
    of oral dental tissue
    Restoration:
    The foundation of teeth
    lmproving function and cosmetics of dental health
    Basic Restoration of Teeth
    Adults oral dental function
    Geriatric oral dental health
    Children's dental health

    Please fill out the patient form below

    Patient Information


    Surname:
    First Name:
    Title:
    ID Number:
    Date of Birth:
    Age:
    Home Address:
    Postal Address:
    Postal Code:
    Telephone [W]:
    Telephone [H]:
    Mobile:
    Email Address:
    Occupation:
    Employer's Name:
    Employer Address:
    Medical Aid:
    Referring Dentist:
    Dentist Telephone:

    Person Responsible For Payment


    Surname:
    First Name:
    Title:
    ID Number:
    Date of Birth:
    Age:
    Home Address:
    Postal Address:
    Postal Code:
    Telephone [W]:
    Telephone [H]:
    Mobile:
    Email Address:
    Occupation:
    Employer's Name:
    Employer Address:
    Medical Aid:
    Medical Aid Number:

    Health Questionnaire


    Rheumatic Fever:
    Diabetes:
    Epilepsy:
    Sinus Problems:
    Heart Problems:
    HIV / AIDS:
    High Blood Pressure:
    Asthma:
    Anticoagulant Therapy:
    Alleries:
    Bleeding-Disorder:
    Hepatitis / Jaundice:
    Lung Problems:
    Kidney Problems:
    Are you on any other medication? (if YES, please list):
    Details of any illness

    Declaration


    The undersigned fully understand this questionnaire and that all information provided is true, and take full responsibility for the cost of any treatment that I will receive

    Kindly take note:


    • This practice is not contracted to any Medical Aid Scheme.
    • The fees are not in accordance with the medical aid tariff
    • All accounts should be paid in full at the completion of your treatment.
    • Full statements will be provided to enable you to reclaim from your Medical Aid.

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