Patient Details - Update
Please use this form to update your details with us. Only complete the sections that have changed.
ABOUT YOU
Title
Please Select
Mr
Mrs
Ms
Miss
Dr
Prof
Other
Full name
*
Surname
*
ID number
Date of birth
*
-
Month
-
Day
Year
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
*
Postal code
*
Is your residential address the same as your postal address?
Yes
No
Residential address
*
NEXT OF KIN
Full name and surname
*
Relationship
*
Please Select
Spouse
Parent
Sibling
Child
Contact number
*
Please enter a valid phone number.
Format: (000) 000-0000.
MEDICAL AID
Have your medical aid details changed since your last visit?
*
Please Select
No — same as before
Yes — please update below
Do you have medical aid?
Yes
No
Main member full name and surname
*
Main member ID number
*
Medical aid scheme name
*
Medical aid number
*
MEDICAL HISTORY
Has your medical history changed since your last visit?
*
Please Select
No same as before
Yes please update below
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?
Yes
No
Please give brief details.
Are you allergic to penicillin or any other medicine?
Yes
No
Please name the medicine(s).
Are you taking any medication at present?
Yes
No
Please name the medication(s).
Have you ever had excessive bleeding requiring treatment?
Yes
No
Please give brief details.
Do you suffer from heart problems, asthma or diabetes?
Yes
No
Please specify which condition(s) and any relevant details.
Have you had any serious illness, including infectious diseases?
Yes
No
Please indicate which illness(es).
For women: are you pregnant?
Yes
No
Not applicable
Please indicate how many weeks (approx.).
Are you currently taking, or have you ever taken, Fosamax (bisphosphonates)?
Yes
No
Please give brief details.
FEES AND PAYMENT OF ACCOUNTS
Accounts are due for settlement on the day of treatment by cash, cheque, credit/debit card or electronic transfer (EFT). A computer is available for payment by Internet transfer. Interest will be charged on overdue accounts after 1 month at the maximum rate allowed in terms of the National Credit Act. Appointments not kept, or not cancelled at least 24 hours in advance, will be charged for.
I have read and accept the fees and payment terms above.
*
I have read and accept the fees and payment terms above.
POPIA CONSENT
In line with the Protection of Personal Information Act (POPIA), Patheodent collects and processes your personal information, including health information, for the purpose of providing dental treatment, managing your account, and communicating with you about your care. Your information is kept confidential and is only shared with third parties (such as your medical aid) where necessary for your treatment or where required by law. You have the right to access, correct or request deletion of your information by contacting us.
I consent to Patheodent collecting and processing my personal information for the purposes described above.
*
I consent to Patheodent collecting and processing my personal information for the purposes described above.
SIGN AND SUBMIT
By signing below, I confirm that the information I have provided is accurate to the best of my knowledge.
Signature
*
Date
*
-
Month
-
Day
Year
Date
Patheodent Incorporated | 14 Eaton Road, Tamboerskloof, Cape Town 8001
021 423 5808 | dentists@patheodent.co.za | Practice Number 542 9420
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