Please note that we are a private practice and do not accept medical aids

    Patient Email:

    Particulars of Patient

    Surname:

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    Date of Birth:

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    A Relative that does not live at the above address

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    Medical aid and Main Member details

    WE ARE A PRIVATE PRACTICE AND DO NOT ACCEPT MEDICAL AIDS: MEDICAL AID INFORMATION SUPPLIED WILL REFLECT ON YOUR ACCOUNT FOR CLAIMING PURPOSES.YOU CLAIM DIRECTLY FROM YOUR MEDICAL AID USING THE STATEMENT THAT WE WILL PROVIDE ON THE DAY OF THE TREATMENT

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    EmailPhoneSMSWhatsapp

    How did you get to know about us?
    FriendDrPasserbyInternetFacebookInstagram

    Medical History

    Does one of the following apply to your medical background?

    Pregnant

    Hepatitis

    Reaction to local anaesthetic

    Rheumatic Fever

    Bleeder

    Heart Condition

    HIV/Aids

    Diabetic

    Porphyria

    Epileptic fits

    High/Low Blood Pressure

    Allergies

    Please state any allergies

    Please state any previous operations/Artificial replacements/heart operations or valve replacements

    Medications

    Please state the reason for visiting SmileSolutions

    Agreement by Patient

    I agree and understand that the contract is entered into by me and the practice and NOT the medical aid.
    I understand that the payment of services rendered remains my responsibility and as this is a PRIVATE PRACTICE payment will be made immediately.
    I agree and undertake to cancel all appointments not less that 24(twenty four) hours prior to such, should I fail to cancel, I will remain liable for R500 per half hour of late cancellation. Appointments longer than one hour will require cancellation 48 (forty eight) hours before the scheduled appointment.

    All accounts are charged at private practice fees and remain my liability.
    I agree that should my account be handed over for collection, I should be liable for all attorney and own client fees, collection charges and all disbursements.
    I agree that the account and payment of account is subject tot the Prescribed Rate of Interest Act and that I remain for mora interest on accounts that have not been settled within 60 days. I agree to inspection of and negative listing of my credit information should my account remain outstanding.
    I choose the above address as my domicilium.

    I hereby declare that the information above is true and correct. I have read the agreement and agree to the terms.

    Signature

    Date:

    Pictures of face and mouth