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
  • Medical Aid
  • General Health
  • Health Conditions
  • Medical Info

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

Email

ID Number

Date of Birth

Person Responsible for Payment

Name

Home Address

Work Address

Telephone Home

Work Number

Cellphone

Employer

Telephone Number of Employer

Email

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.