Patient Form

PATIENT INFORMATION FORM AND FINANCIAL AGREEMENT CONTRACT

Kindly complete this form, which will become our office record and your financial agreement contract and will assist us in compiling a correct treatment plan.

ALL INFORMATION WILL BE KEPT IN THE STRICTEST OF CONFIDENCE

PATIENT INFORMATION


Surname:
First Names:
Date of Birth:
Home Address:
Work Address:
Occupation:
Postal address:
Tel (W) :
Tel (H):
Cell:
I.D Number:
Email:

FINANCIALLY RESPONSIBLE PARTY INFORMATION (If not the same as above)


Surname:
First Names:
Date of Birth:
Home Address:
Work Address:
Occupation:
Postal address:
Tel (W) :
Tel (H):
Cell:
I.D Number:
Email:

MEDICAL AID (In order for you to claim back from your medical aid)


Name:
Medical Aid number:
Main Member:

DEPENDANTS


Name:
Date of Birth:
Remarks:

NEAREST FAMILY MEMBER / FRIEND


Name:
Relationship:
Tel (H)
Tel (W):
Cell:

PLEASE NOTE THE FOLLOWING:

  1. The practice is contracted out of medical aid and therefore does not limit itself to NHRPL fees.
  2. A description of the practice fee structure and a cost estimation will be prepared at any time on request
  3. This practice is not a registered credit provider and may not extend credit.
  4. Fees are strictly payable after every visit.
  5. Appointment must be cancelled at least 6 HOURS before the time, otherwise a fee of R300 per half hour will be charged
  6. Should you have a genuine financial problem, please feel free to discuss this with me
  7. Please inform me immediately of any changes in your address or patient details.
  8. All accounts over 30 days will be charged 5% interest.

HEREBY STATE THAT I FULLY UNDERSTAND ALL THE ABOVE MENTIONDED FACTS AND AM AWARE THAT THIS IS A LEGAL AND BINDING CONTRACT OF ARRANGEMENT BETWEEN DR JJ SERFONTEIN AND MYSELF.

Signature

Date

Health Information

Referral Information


How did you first hear of our practice?
If other, please List:

Patient Name:
Birth Date:
Name of Physician
Phone
Have you ever had any of the following? Please check those that apply:

Conditions with Additional Information Required

Congenital Heart Disease
Have you had this condition
Residual Defects
Date
Heart Surgery
Have you had Heart Surgery
Date
Artificial Joints
Do you have Artificial Joints
Date
Type
Pregnancy
Are you pregnant
Due Date
Please list any allergies
Please list any disease, condition or problem not listed above?
Do you smoke or use smokeless tobacco
Have you ever had any complications following dental treatment?
Have you ever had excessive bleeding requiring special treatment?
Have you been admitted to hospital or needed emergency care during the past two years?
Have you ever taken Bisphosphonate Medications?(List Below)
Drug/Medication
Dosage
Duration & Reason
Fosamax
Skelid
Didronel
Actonal
Boniva
Aredia
Zometa
Reclast
Are you now under the care of a physician?
Are you taking any drugs or medications (Prescription, Over the Counter)? (List Below)
Medication Name
Dose
Reason
Warfarin
Antidepressants
Codeine (Disprin)
Cortisone
Ginko Biloba
St Johns Wort

To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I will inform the doctors at the next appointment without fail.

Signature
Date

CONSENT FOR SERVICES

Patient Name

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.
I consent to the dentist’s use and disclosure of my records (or my child’s records) to carry out treatment, to obtain payment, and for those activities and health care operations that are related to treatment or payment. I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me.

I understand that I am financially responsible for payment in full of all services rendered, regardless of what my medical aid or payer of my dental benefits pays. By signing this statement, I acknowledge that I received a copy of the financial policy of this office and I agree to the terms set forth in the policy. All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for in cash at the time services are performed.

I grant my permission to you and your assignee, to telephone me at home or at my work to discuss matters related to this form and my account. I consent to the use of the provided email address(es) for appointment reminders and any other direct communication from this office.

I have read the above conditions of treatment and payment and agree to their content.

Patient, Parent or Guardian

Signature
Relationship to Patient
Date

Guarantor of payment/responsible party

Signature
Relationship to Patient
Date
Right to Revoke: You will have the right to revoke these Consents at any time by submitting to our office in writing, notice of your revocation. Please understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that we may decline to treat you or to continue treating you if you revoke this Consent.

DENTAL HEALTH QUESTIONNAIRE

What is your main reason for making this appointment:
When was your last dental visit?
Your last dental cleaning?
Do any of the following cause you discomfort?
Hot
Cold
Sweets
Chewing
Do you have any difficulty chewing food on either side of your mouth?
Have you ever had a grinding appliance, guard, or any other treatment for your bite?
Do you have any digestive problems?
Do you have any missing teeth?
Have your missing teeth ever been replaced?
If so, how?
Do you have any loose teeth?
Do you have any cracked or broken teeth?
Do you do any of these more than once per day?
Drink soda drinks
Use breath mints
Chew gum
Do you ever clench of grit your teeth?
Do you ever have/or ever had any headaches?
Do you ever have/ or ever had ear pain?
Do you ever have/or ever had tension, aching, or a tired feeling in you jaws?
Do you ever have/or have you ever had clicking or popping in your jaws or ears?
Have you ever had any gum problems?
If yes, was it treated
Do/did your parents have dentures or gum disease?
Do your gums bleed while brushing or flossing?
Do you floss your teeth more than 3 times per week? (Be honest – most don’t floss!)
Are you a smoker?
Have you ever had orthodontic treatment?
Have you ever whitened (bleached) your teeth?
Have you ever considered tooth whitening?
Are you unhappy with your smile?
If yes, what would you change

Straighten/get rid of spaces
Whiten
Make teeth Larger
Make teeth Smaller
Other
Does dental treatment cause anxiety for you?
Have you ever had an unpleasant experience at the dentist?
Would you ever consider being sedated for dental treatment?
Patient's Name
Date
Signature

Financial Policy

This statement is to inform you of our financial policy. Your understanding of this policy is very important to us and will help us to facilitate excellent service to you while maintaining our professional relationship. We are committed to helping you obtain and maintain optimum oral health and aesthetics.

Patients without Medical Aid:

Full payment is due at the time of treatment

Patients with Medical Aid:

The patient portion and any deductible/co-payment will be due at the time of treatment.

  • All charges you incur are your responsibility regardless of your medical coverage.
  • A description of the practice fee structure and a cost estimation will be prepared at any time on request
  • We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your medical aid company. Your medical aid policy is a contract between you, your employer, and the medical aid company.
  • Not all dental services are covered benefits in all contracts.
  • We suggest and recommend treatment based on the need, not your medical aid coverage or eligibility.
  • Regardless of being able to verify eligibility prior to treatment, you are still expected to pay in full at the time of service.
  • Due to medical aid policies and companies differing greatly and being very complex we can only estimate, in good faith, your coverage and patient portion of services.
WE ACCEPT THE FOLLOWING PAYMENT METHODS
  • Cash
  • Credit Cards
  • Electronic Funds Transfer
Finance Charges

Unpaid balances will be subject to a 1 ½ % per month finance fee

Our staff is always available to assist you with your financial and medical aid questions, which they will answer to the best of their ability.

PAYMENT PLANS:

In certain cases you may make financial arrangements by consulting with our office personnel prior to service. Prior to any payment plans being instituted, at least one-third of the total amount due must be paid.

MINOR PATIENTS:

The adult accompanying a minor and the parents (or guardian of the minor) are responsible for full payment. For unaccompanied minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card, or payment by cash at time of service has been verified.

MISSED APPOINTMENTS:

Unless cancelled at least 48 hours in advance, during business hours, a charge of R300 per half hour scheduled appointment will be allocated to your account (min R 300). Please help us serve you better by keeping scheduled appointments.