Smile Solutions | Patient Form

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

Patient Email:

Particulars of Patient

Surname:

Full Names:

Title:

Nick Name:

Date of Birth:

WhatsApp:

ID or Passport Number:

Tel(W):

Address:

Cell:

Occupation:

Employer:

A Relative that does not live at the above address

Surname:

Name:

WhatsApp:

Cell:

Relationship:

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

Surname:

Full Names:

ID or Passport Number:

Marital Status:

Medical Aid:

Member No:

Home Address:

Postal Address:

Employer:

Cell No:

Work Adress:

WhatsApp:

Tel (W):

Email:

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