BOOK ONLINE

Online Patient Application Form

TREATMENT PLAN AND COSTS FOR TREATMENT

Patient Disclaimer


Please read and sign this disclaimer to continue.

Dear Patient

We believe it is essential for you to be informed about treatment plans and / or treatment costs that may be proposed or done.

In order for you to consider the fees we are quoting, you need to be aware of the background to determining fees, so that you do not confuse the "medical aid benefit" with the fee we are quoting for your treatment.

In order to provide a quality dental service to our patients we have used the "Ethical Tariff Guideline" determined by the Health Proffessions Council of South Africa (HPCSA). We annually review and adjust our fees in relation to the CPI.

We strongly recommend that, if applicable, you submit all treatment cost estimates to your funder, before commencing treatment, so that you are able to determine what, if any, portion of your  account will be retrievable and for how much you will be personally responsible.

Our practice policy is that all accounts are settled on the day of treatment.

Should extended treatment be required, a suitable payment plan may be arranged before treatment commences. We may also require an upfront payment for extensive treatment.

Legal Costs:

Should the practice commence legal proceedings, the patient undertakes to pay all legal costs relating to the recovery of the outstanding monies in respect of professional services rendered, including attorney fees on an attorney own client scale, collection commission and tracing costs.

We welcome discussion about any aspect of your treatment or the cost thereof. /p>

Field is required!
Field is required!
You must tick this box to continue.
By ticking this box, you confirm that you have read the disclaimer and are in full agreement with it.
Field is required!
Sorry, this is a mandatory field. Please accept the disclaimer before continuing.

PATIENT DETAILS:

  • - select your title -
  • Mr.
  • Mrs.
  • Mis.
  • Dr.
  • Ds.
  • Mis.
  • Prof.
  • Prof.
- select your title -
Field is required!
Field is required!
Your First Name
Field is required!
Field is required!
Your Last Name
Field is required!
Field is required!
Are you a South African Citizen?
Field is required!
Field is required!
Your ID Number
Field is required!
Field is required!
Your Date of Birth
Field is required!
Field is required!
Your Mobile Number
Your Mobile Number
Invalid phonenumber!
Invalid phonenumber!
Your Home Number
Your Home Number
Invalid phonenumber!
Invalid phonenumber!
Your Work Number
Your Work Number
Invalid phonenumber!
Invalid phonenumber!
Your E-mail Address
Field is required!
Field is required!
Verify your email by retyping it here.
Your email address does not match.
Your email address does not match.
Your Residential Address
Field is required!
Field is required!
Your Residential Suburb
Field is required!
Field is required!
Is your postal address the same as your physical address?
Field is required!
Field is required!
If your postal address is the same as your physical address, then toggle the switch to yes.
Your Residential Address
Field is required!
Field is required!

PERSON RESPONSIBLE FOR PAYMENT:

Is the person paying for the treatment the same as the person receiving it?
⚠ Please answer this question first before continuing. By default, this toggle is set to 'No'. Toggel to 'Yes' if the previous details are the same as the ones below.
Field is required!
Field is required!
  • Payer's Title
  • Mr.
  • Mrs.
  • Mis.
  • Dr.
  • Ds.
  • Mis.
  • Prof.
  • Prof.
Payer's Title
Field is required!
Field is required!
Payer's First Name
Field is required!
Field is required!
Payer's Last Name
Field is required!
Field is required!
Is the Payer a South African Citizen?
Field is required!
Field is required!
Payer's ID Number
Field is required!
Field is required!
Payer's Date of Birth
Field is required!
Field is required!
Payer's Mobile Number
Payer's Mobile Number
Invalid phonenumber!
Invalid phonenumber!
Payer's Home Number
Payer's Home Number
Invalid phonenumber!
Invalid phonenumber!
Payer's Work Number
Payer's Work Number
Invalid phonenumber!
Invalid phonenumber!
Payer's E-mail Address
Field is required!
Field is required!
Verify the email by retyping it here.
Your email address does not match.
Your email address does not match.
Payer's Postal Address
Field is required!
Field is required!

MEDICAL AID DETAILS:

Do you have Medical Aid?
By default, the option is set to "Yes". Please toggle the switch to "No" if the answer is false.
Field is required!
Field is required!
Is the main medical aid member a South African Citizen?
Field is required!
Field is required!
Main member's name and surname
Field is required!
Field is required!
Main Member's ID number
Field is required!
Field is required!
Medical Aid Agency:
Field is required!
Field is required!
Medical Aid Number
Field is required!
Field is required!
By default, the following questions are set to "No". Please toggle the switch to "Yes" for any qustion where the answer is "True".
Have you been under the care of a doctor in the past year?
Field is required!
Field is required!
Are you allergic to penicillin / other medicine?
Field is required!
Field is required!
Please specify which medication/s you are allergic to.
Field is required!
Field is required!
Are you taking any medication at present?
Field is required!
Field is required!
Please specify which medication/s you are currently taking.
Field is required!
Field is required!
Have your ever had excessive bleeding requiring treatment?
Field is required!
Field is required!
Do you suffer from heart problems, asthma, diabetes?
Field is required!
Field is required!
Please specify what medical problems you suffer from.
Field is required!
Field is required!
Have you had any serious illness, including infections diseases?
Field is required!
Field is required!
Please specify what serious illness you suffer from.
Field is required!
Field is required!
For women – please indicate if you are pregnant..
Field is required!
Field is required!
Are you or have you taken Fosamax(Bisphosponates)?
Field is required!
Field is required!

FEES AND PAYMENT OF ACCOUNTS

Accounts are due for settlement on day of treatment by Cash, cheque, credit card or direct transfer(EFT). A computer is available for payment by Internet Transfer.

Interest will be charged on overdue accounts after 1 Month at maximum rate allowed in terms of the National Credit Act.
Appointments not kept or cancelled 24 hours in advance will be charged for.

Field is required!
Field is required!
Please complete this form by signing and dating it below.
This form was signed on the following date.
Please note, you can only select the current date.
Select a date
Field is required!
Field is required!
Please sign off on this form before submitting.
Use your mouse, finger or stylus (touch screen) to sign this document. Please make sure that you do not sign outside of the frame. You can tap on the trash can to redo your signature..
Field is required!
Field is required!
Please doublecheck all your answers before tapping submit.
Submit

Subscribe to our Newsletter

We are committed to respecting your privacy and will never share or distribute your personal data. Keeping notification and promotions to a minimum, it is also our aim not to spam your mailbox. 

Online Dental Store

More Store Links

Get In Touch

Please ensure to read our  Privacy and Personal Data Policy by clicking here.

COPYRIGHT © 2024 PATHEODENT INC

Register

To prevent spam accounts, this website does not allow you to create a customer account prior to ordering. Once you have completed your billing details on the checkout page and click “Place Order“, a customer account will automatically be created for you and you will be automatically logged in on the website as a customer. Please check both your email INBOX and SPAM folder for your welcome email and login credentials for future purchase or to view your order history.

PLACE YOUR FIRST ORDER HERE

login

Login to Patheodent to see your Current and Past Orders. Logging in will also automatically filling your  Billing and Delivery details for future purchases.

[theme-my-login action="login"]

I have lost my password! 

This website uses cookies to ensure you get the best experience on our website.

By continuing to use this website you automatically agree to the terms and conditions as set out by our Privacy Policies. 

ACCEPT
DECLINE