Patient Information

    PATIENT DETAILS

    Title

    Surname*

    Full Names*

    Contact number*

    ID / Passport Number

    Date of Birth

    PERSON RESPONSIBLE FOR THE ACCOUNT

    Title

    Surname

    Full Names

    Cell Number

    Email

    Employer

    Home Address

    Address Line 1

    Address Line 2

    City

    Postal Code

    Work Address

    Address Line 1

    Address Line 2

    City

    Postal Code

    Home Number

    Work Number

    Postal Address

    Address Line 1

    Address Line 2

    City

    Postal Code

    NEAREST FAMILY/EMERGENCY CONTACT

    Name

    Contact number

    MEDICAL AID DETAILS CONTACT

    Medical Aid Plan

    Dependent code

    Medical Aid Number

    Main Member Name

    Main Member ID Number

    HEALTH QUESTIONNAIRE

    Do you have or have you had any of the following illnesses:

    High/ low blood pressureAnginaRheumatic/scarlet feverCongenital heart diseaseAsthma/bronchitis/emphysema/TBJaundice/hepatitis/other liver diseaseKidney diseaseDiabetesEpilepsyBleeding tendencyAnemiaArthritisMuscular diseaseAllergiesOther

    Have you ever taken/are currently taking any of the following medication

    Cortisone/other steroidsAnti-depressantsTranquilizers/sedativesAnti-coagulants/blood thinnersBlood pressure/anti-hypertensivesThyroid drugsContraceptivesBisphosphonate treatment / Bone densityOther

    Do you have any artificial prosthesis? (Heart valves/knees/hips)

    Have you or any family member had any complications or unusual reactions to local/general anesthesia?

    Female patients: are you pregnant/trying to get pregnant?


    I declare that the above information is correct and that I shall make known any changes in my
    health to the treating practitioner. I further declare that the above-mentioned address is the
    account holder’s permanent address. I accept full responsibility for my account. I give consent to
    be treated by the dentist after consultation and with my full understanding of the treatment plan
    and costs thereof. This is a legal and binding contract.

    Name

    Signed Date