Which dentist are you seeing?


PATIENT DETAILS


PERSON RESPONSIBLE FOR THIS ACCOUNT

SELF/PARTNER/PARENT (complete all below)


MEDICAL HISTORY

Are you Allergic to
any medicine?

Do you have
Artificial Heart valves?

Do you have
Hypertension?

Do you have
Joint Replacements?


Do you have an
allergic nature?

Do you have an
Cardiovascular Disease?

Do you have a
Stomach ulcer?

Have you had
Organ transplants?


Do you have
Diabetes?

Do you have
Blood clotting problems?

Do you have a
Pacemaker?

Do you have
Mouth cancer?


Are you have
HIV +?

Do you have
Rheumatic fever?

Do you have
Sinus Problems?

Are you
Pregnant?

You agree that we may:

I herewith give permission for myself/parent or guardian of above person, that any digital photos or x-ray images may be used for any case study, research or submission. Make enquiries regarding information given to us by you. Seek information from any credit bureau when assessing my application. That you may give my personal information to any Bureau or tracing agents if my account is NOT paid in full. You may obtain personal information to any Bureau or companies if you find it necessary or to benefit me. I accept full responsibility for any outstanding amount on this account. ALL outstanding amounts after 90 days I am aware will have a 24 %/ pa (2%/month) interest charged applied to my account. I confirm all above detail is correct and I will update any changes.


THIS PRACTICE DOES NOT CHARGE MEDICAL AID RATES, WE REQUIRE IMMEDIATE PAYMENT AS WE DO NOT SUBMIT.

Please sign below

[ X ]

GIVE US A CALL

TO SCHEDULE AN APPOINTMENT.