The Family Dentist Patient Signup Details

Welcome to The Family Dentist.

We pride ourselves in saving people's teeth, one tooth at a time. Now, we thought we'd go one bigger and save our planet by going paperless. Please help us grow our family tree by filling out your details below.
The Main Germ Fighter

Main Member
Names*

TitleFirst NamesSurname
ID Number/Passport Number*
Date of Birth*

DayMonthYear
Home Tel
e.g. 012 123 4567
Cell*
e.g. 082 123 4567
E-mail Address*
Additional E-mail Address
example@example.com
Physical Address*

Street Address

Suburb

CityState / Province

Postal / Zip Code
Employer*
Occupation
Work Tel
e.g. 012 123 4567
Employer's Address

Street Address

Suburb

CityState / Province

Postal Code
Your Germ Fighting Family
No of Dependents
1. First Names
Date of Birth*

DayMonthYear
2. First Names
Date of Birth*

DayMonthYear
3. First Names
Date of Birth*

DayMonthYear
4. First Names
Date of Birth*

DayMonthYear
Your Closest Germ Fighting Friend

Next of Kin
Name*

First NameLast Name
Relationship
i.e. Parent, Spouse, Friend
Contact Details*
e.g. 012 123 4567 / 082 123 4567
Alternative Contact Details
e.g. 012 123 4567 / 082 123 4567
Your Sometimes Helpful Back Up

Medical Aid
Medical Aid Name
Option
Medical Aid Number
Any Health Problems?
Have you or any dependent had
Rheumatic Fever
Clotting Disorders
Diabetes
Lung Disorder
Allergies
Cortisone
Epilepsy
Heart Condition
Hypertension
Hip/Knee Replacement
Are you pregnant?

YesNo
Are you taking any medication?

YesNo
What medication are you taking?
Any other medical conditions?
How Did You Hear About Us?
InternetFacebookReferralSchool VisitOutdoor SignageBNI
Who referred you?
What Chapter are they from?
Important Stuff
Since you are responsible for your medical aid account, the medical aid is more likely to reimburse you directly should you submit any claims. It is for this reason that we do not submit accounts to any medical aids. You will be provided with a detailed zero-balance invoice showing your proof of payment should you wish to submit to your medical aid for then to reimburse you.

We accept payments by credit/debit cards or cash. Cash payments qualify for a 5% discount.

Due to the fact that we are booked well in advance, appointments not kept or cancelled at least 12 hours before will be billed at a full consultation rate.
Let's Make it Official
I, the undersigned, confirm that the above details are true and correct and by my signature attached hereto accept and agree to abide by terms and conditions contained hereunder. My signature also gives informed consent for any procedures which may be required.

I understand that I am fully responsible for my account, not my medical aid. I also understand that I am to settle the account immediately after my appointment.

Any accounts that haven't been settled will be handed over to our attorneys for collection. You will be held liable to pay any collection and/or attorney fees on the Attorney Client Scale.

I understand that there are CCTC cameras on the property for the safety of both myself and The Family Dentist team. I understand that in the event that footage is required by authorities, it will be handed over.
I agree to the Terms and Conditions stated above
Signature*
Should be Empty:

The Main Germ Fighter

Your Germ Fighting Family

Your Closest Germ Fighting Friend

Your Sometimes Helpful Back Up

Any Health Problems?

How Did You Hear About Us?

Important Stuff

Let's Make it Official