Online Patient Form - Part 1 of 3

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Patient Information

Party Responsible for Payment Information

If information is same as above, please leave this section blank

Referral Information

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Online Patient Form - Part 2 of 3

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Patient Medical History

Are you allergic to or have you had any reactions to the following?

Have you ever had any of the following?

Please select those that apply

Do you have High blood pressure?
Do you have Low blood pressure?
Have you had Rheumatic fever?
Do you have swollen ankles?
Do you have Fainting/Seizure episodes?
Do you have Asthma?
Have you had a Heart Attack?
Have you had Epilepsy/Convulsion?
Do you have Leukemia?
Do you have Diabetes?
Do you have Kidney Disease?
Do you have HIV or AIDS?
Do you have a sexually trans. Disease?
Do you have Heart Disease?
Do you have a Cardiac pacemaker?
Do you have Angina?
Are you frequently tired?
Do you have Anemia?
Do you have Emphysema?
Do you have Cancer?
Do you have Arthritis?
Do you have Joint Replacement?
Do you have Hepatitis/Jaundice?
Do you have a Thyroid Problem?
Do you have Heart Trouble?
Do you have Chest Pains?
Have you had a stroke?
Do you have Hayfever/Allergies?
Do you have Tuberculosis?
Have you had Radiation Therapy?
Do you have Glaucoma?
Have you had recent Weight loss?
Do you have Liver Disease?
Do you have Sinus Problems?
Do you have Stomach Ulsers?
Do you have Respiratory Problems?
Do you have Mitral Valve Prolapse?
Do you have a family history of Diabetes?
Do you have a Persistent Cough?

Women Only:

Patient Dental History

Are you experiencing any of the following problems in your jaw:

I certify that I have read and understand the above information to the best of my knowledge. The above questions have been accurately answered. I understand that providing incorrect information can be dangerous to my health. I authorize the dentist to release any information including the diagnosis & the records of any treatment or examination rendered to me or child during the period of such dental care to third party payers and or health practitioners.
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Online Patient Form - Part 3 of 3

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Financial Policy

We will assist you in every way possible to maximize your dental insurance benefits. Your policy is an agreement between you and your insurance company, not between your insurance company and our office. We can make no guarantee of any coverage, but we will do our best to see that you receive your maximum benefits.

Please initial below, acknowledging that you have read & agree to comply:

I understand that I am responsible for my total obligation, should my dental benefits result in less coverage than anticipated, regardless of the reason of non-payment. Not all the services we provide are covered benefits. Benefits differ from one company's benefits to another. Fees for non-covered services, along with deductibles & co-payments are due at the time of treatment.

I am responsible for keeping track of and being familiar with my dental insurance benefits (including procedure frequencies, waiting periods and yearly maximums/deductibles) Please ask the front desk at any time for ant type of procedures codes/information on upcoming appointments, so that you may call your insurance to find out limitations and frequency details.

Upon the circumstance that my account is sent to a collection agency (this action would incur after 90 days of billing statement and a final notice) my total account balance would be increased by 20% for collection costs. This 20% increase would include attorney fees, court costs and all other related costs.

I am aware that when I make a payment, Dental Professionals accepts cash, personal checks, VISA, MasterCard, American Express, Citi health, and Care Credit.

I understand that extended payment plans (Incred Medical Finance) are available upon credit approval. otherwise, my payment is expected at the time my services are performed. When extensive dental care is necessary, arrangements may be made with the financial coordinator. Please have these options reviewed prior to beginning treatments.

In case of minors: the parent or guardian accompanying the minor to the appointment is responsible for full payment. In case of divorce/separation, the parent/guardian that brought the minor to the appointment is responsible for payment, no exceptions.

Our dental office will charge a R300 fee for cancellations and appointment failures without a 24 hour notice.