Patient Information
Payment Agreement
Please fill in the information below or download the Patient Information as a hardcopy below the form.
Payment Agreement
Health Questionnaire
Your Dentist is concerned about your health. Oral treatment may be influenced by general health. Please complete all particulars as clearly and fully as you can. Thank you.
Health Questionnaire
Tick the boxes below that apply to you.
Health Questionnaire
Tick the boxes below that apply to you.
Patient Details
I choose the above address as the domicilium citandi executandi for all purposes in terms of this agreement.
OR
Person Responsible for Payment
Medical Aid Details
Please tick the box if you do not have medical aid
General
Your General Health
How would you describe your present health?
Are you presently being treated by any specialist e.g. Physician or, Surgeon?
Tick any of the following which you may have or have had
Conditions and Disorders
Liver Disorders
Heart Conditions
Vascular Conditions
Lung Conditions
Do you have any other disease, condition or problem not listed above that you feel we should know about?
Medical Information
Are you a smoker?
Are you presently taking any medication?
Apart from the above, have you ever taken any of the following
Are you allergic to any medication or substances?
Female Patients
Are you pregnant?
Are you on the pill?
General Medical Info
Have you been hospitalised during the past two years?
Are you a member of MEDIC-ALERT?
By ticking the box below you fully understand and agree to the Terms of Payment and that the information on this form is correct
This form is also available as a hardcopy. Click the button below to download the Patient Information form.