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
Title
First Names
Last Name
Nickname
Home Address
Postal Address
I choose the above address as the domicilium citandi executandi for all purposes in terms of this agreement.
Telephone Home
Work Number
Cellphone
ID Number
OR
Passport Number
Date of Birth
Person Responsible for Payment
Name
Home Address
Work Address
Telephone Home
Work Number
Cellphone
Employer
Telephone Number of Employer
ID Number
Medical Aid Details
Medical Aid
Please tick the box if you do not have medical aid
Plan
Name of Main Member
M/A Number
Main Member ID Number
M/A Dependant Number
Address (if different from above)
Relationship to Patient
Cellphone
General
Referred By
Telephone Number of Referral
Home Language
Next of Kin's Name
Telephone Number of Next of Kin
Your General Health
How would you describe your present health?
Are you presently being treated by any specialist e.g. Physician or, Surgeon?
If yes, please give details
Tick any of the following which you may have or have had
Conditions and Disorders
Liver Disorders
Heart Conditions
Other 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?
If yes, please detail below
Medical Information
Are you a smoker?
Are you presently taking any medication?
If yes, list any medication you are taking presently below
Apart from the above, have you ever taken any of the following
If you have ticked any of the above, please name the medication(s) below
Are you allergic to any medication or substances?
If yes, please give details
Female Patients
Are you pregnant?
If yes, how many weeks?
Are you on the pill?
General Medical Info
Have you been hospitalised during the past two years?
If yes, please give details below
Are you a member of MEDIC-ALERT?
Patient Name
Capacity
By ticking the box below you fully understand and agree to the Terms of Payment and that the information on this form is correct
Date
This form is also available as a hardcopy. Click the button below to download the Patient Information form.