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:

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ID Number:

Date of Birth:

Age:

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Postal Address:

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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:

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Medical Aid:

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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.