Patient Registration Form

1. PATIENT DETAILS:

Surname / Van: *

ID No / ID Nr: *

Full Names / Volle Name: *

Title / Titel:

Gender / Geslag:

Occupation / Beroep:

Email / E-pos: *

Marital Status / Huwelikstatus:

Employer / Werkgewer:

Cell No / Sel Nr: *

Work Tel No / Werk Tel Nr:

Guardian Cell No / Voog Sel Nr:

Home Tel No / Huis Tel Nr:

Upload ID document *

Upload medical aid card

Upload Dr referral letter

Upload X-rays (within the last 6 months)

2. MEDICAL AID DETAILS:

Medical Aid / Mediese Fonds:

Membership No / Lid Nr:

Referring Dr Tel No. / Tel Nr Tandarts:

Option / Plan:

Dependant Code / Afhanklike Kode:

Referring Dr / Verwysende Tandarts:

Tel No House Dr / Tel Nr Huis Dr:

3. DETAILS OF MAIN MEMBER:

PERSON RESPONSIBLE FOR ACCOUNT

Surname / Van:

ID No / ID Nr:

Full Names / Volle Name:

Title / Titel:

Occupation / Beroep:

Employer / Werkgewer:

Home Tel No / Huis Tel Nr:

Work Tel No / Werk Tel Nr:

Cell No / Sel Nr:

Email / E-pos:

Marital Status / Huwelikstatus:

Home Language / Huistaal:

Postal Address / Posadres:

Physical Address / Woonadres:

Code / Kode:

4. NEXT OF KIN:

Next of Kin / Naasbestaande:

Tel No / Tel Nr:

Address / Adres:

Postal Code / Poskode:

5. AUTHORISATION:

I agree that the address above is my chosen domicilium citandi et executandi for purposes of delivering and serving of all invoices, documents and legal processes. I further agree that in the event of medical aid not paying any award due for whatsoever reason, that I am still liable in my personal capacity to pay the amount owing. I further agree that in the event of my account being handed over to attorneys, that I will pay all attorneys fees and costs on attorney and client scale together with further collection commission.

I agree *

Empowering Smiles, Transforming Lives.

Driven by precision and compassion, our maxillofacial and oral surgeon specialises in enhancing both the aesthetics and functionality of the face and oral region.