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Online Patient Application Form

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>

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PATIENT DETAILS:

  • - select your title -
  • Mr.
  • Mrs.
  • Mis.
  • Dr.
  • Ds.
  • Mis.
  • Prof.
  • Prof.
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Your First Name
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Your Last Name
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Are you a South African Citizen?
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Your ID Number
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Your Date of Birth
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Your Mobile Number
Your Mobile Number
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Your Home Number
Your Home Number
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Your Work Number
Your Work Number
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Your E-mail Address
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Verify your email by retyping it here.
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Your Residential Address
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Your Residential Suburb
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Is your postal address the same as your physical address?
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If your postal address is the same as your physical address, then toggle the switch to yes.
Your Residential Address
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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.
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  • Payer's Title
  • Mr.
  • Mrs.
  • Mis.
  • Dr.
  • Ds.
  • Mis.
  • Prof.
  • Prof.
Payer's Title
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Payer's First Name
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Payer's Last Name
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Is the Payer a South African Citizen?
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Payer's ID Number
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Payer's Date of Birth
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Payer's Mobile Number
Payer's Mobile Number
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Payer's Home Number
Payer's Home Number
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Payer's Work Number
Payer's Work Number
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Payer's E-mail Address
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Payer's Postal Address
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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.
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Is the main medical aid member a South African Citizen?
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Main member's name and surname
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Main Member's ID number
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Medical Aid Agency:
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Medical Aid Number
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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?
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Are you allergic to penicillin / other medicine?
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Please specify which medication/s you are allergic to.
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Are you taking any medication at present?
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Please specify which medication/s you are currently taking.
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Have your ever had excessive bleeding requiring treatment?
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Do you suffer from heart problems, asthma, diabetes?
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Please specify what medical problems you suffer from.
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Have you had any serious illness, including infections diseases?
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Please specify what serious illness you suffer from.
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For women – please indicate if you are pregnant..
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Are you or have you taken Fosamax(Bisphosponates)?
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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.

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This form was signed on the following date.
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As of 1 August 2025, all orders will be placed using Guest Checkout only. If you experience any issues with your order, please contact us via the online contact form. Be sure to include your Order Number and the e-mail address used at checkout.

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