New Patient Form — Patheodent

WELCOME TO PATHEODENT

Comprehensive dental treatment in a comfortable and professional environment. This form takes about 5 minutes to complete and helps us prepare for your visit. Please answer as fully as you can. If you have any questions, call us on 021 423 5808 or email dentists@patheodent.co.za.
ABOUT YOU
Title
Full name

First NameMiddle NameLast Name
Identity document number
Date of birth

MonthDayYear
Date
Mobile number
Please enter a valid phone number.Format: (000) 000-0000.
Home telephone
Please enter a valid phone number.Format: (000) 000-0000.
Work telephone
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Postal address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Is your residential address the same as your postal address?
Residential address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Emergency contact name and surname

First NameLast Name
Emergency contact telephone
Please enter a valid phone number.Format: (000) 000-0000.
Previous dentist
House doctor / GP
HOW DID YOU HEAR ABOUT US?
How did you hear about Patheodent?

Other
If other, please specify
WHO IS RESPONSIBLE FOR PAYMENT?
Are you responsible for your own account?
Full name and surname of person responsible for payment

First NameLast Name
ID number
Mobile number
Please enter a valid phone number.Format: (000) 000-0000.
Home telephone
Please enter a valid phone number.Format: (000) 000-0000.
Work telephone
Please enter a valid phone number.Format: (000) 000-0000.
Email address
example@example.com
Postal address

Street Address

Street Address Line 2
CityState / ProvincePostal / Zip Code
Employer name and address
MEDICAL AID
Do you have medical aid?
Main member name and surname

First NameLast Name
Main member ID number
Medical aid scheme name
Medical aid number
MEDICAL HISTORY
Please answer each question. If you answer Yes, a follow-up field will appear so you can give us more detail.
Have you been under the care of a doctor in the past year?
Please give brief details.
Are you allergic to penicillin or any other medicine?
Please name the medicine(s).
Are you taking any medication at present?
Please name the medication(s).
Have you ever had excessive bleeding requiring treatment?
Please give brief details.
Do you suffer from heart problems, asthma or diabetes?
Please specify which condition(s) and any relevant details.
Have you had any serious illness, including infectious diseases?
Please indicate which illness(es).
For women: are you pregnant?
Please indicate how many weeks (approx.).
Are you currently taking, or have you ever taken, Fosamax (bisphosphonates)?
Please give brief details (dosage, dates if known).
TREATMENT PLAN AND COSTS
Treatment plan and costs
I have read and accept the treatment plan and cost information above.
FEES AND PAYMENT OF ACCOUNTS
Fees and Payment of Accounts
I have read and accept the fees and payment terms above.
PHOTOGRAPHY AND X-RAY CONSENT
Clinical photographs and x-rays may be taken during your treatment for teaching purposes. These materials will be handled with care and privacy, and used only as permitted by the practice.
Do you consent to the taking of photographs or the use of x-rays of your procedure for teaching purposes?
MARKETING COMMUNICATIONS
Patheodent may occasionally send newsletters and updates. Your email address will be kept private and will not be shared with third parties.
Do you give your permission to receive newsletters and marketing material from Patheodent?
POPIA CONSENT
POPIA Consent Information
I consent to Patheodent collecting and processing my personal information for the purposes described above.
SIGN AND SUBMIT
Confirmation
Digital Signature
Date

MonthDayYear
Date
Should be Empty:

WELCOME TO PATHEODENT

ABOUT YOU

HOW DID YOU HEAR ABOUT US?

WHO IS RESPONSIBLE FOR PAYMENT?

MEDICAL AID

MEDICAL HISTORY

TREATMENT PLAN AND COSTS

FEES AND PAYMENT OF ACCOUNTS

PHOTOGRAPHY AND X-RAY CONSENT

MARKETING COMMUNICATIONS

POPIA CONSENT

SIGN AND SUBMIT