Patient Registration Form Patient Registration

Patient Registration Form - Please complete

Once submitted, our reception staff will contact you to confirm an appointment.

Title

Initials

Preferred Language

English Afrikaans

Surname

First Names

SA ID / Passport No

Date of birth

Occupation

Employer

Cell

Dentist

GP/Specialist

Reason for Referral

Wisdom Teeth Removal of Teeth Dental Implants Orthodontic Exposure

Responsible for Payments

Yes No

Name of Fund

Plan / Option

Number

Principal Member

ID No

Title

Initials

Surname

First Names

ID No

Date of birth

Home Address

Marital Status

Married Divorced Single

Postal Address

Code

Occupation

Employer

Tel (H)

(W)

Cell

State all allergies you suffer from (e.g Penicillin)

State any other serious diseases:

State all medications that you take

State all disabilities

State previous operations:

State previous problems with anaesthetic

State Osteoporosis treatment

Title

Initials

Surname

Relationship

Tel (H)

Cell

The purpose of release of your information is for Continuing Medical Care to other treating Health Care Providers, Legal Purposes, Personal Use, Claims from Medical Schemes, and Insurance. The health information to be released will include Medical History & Clinical findings, Post-Operative Reports, Lab/Pathology Reports, Consultation Reports, Medical Legal Reports, X-ray Reports/Images, or any other information as discussed with Dr Viljoen. I understand that I have the right either to give consent or refuse consent. I have the right to decide that I do not want to disclose my private health information. I have the right to withdraw any consent given or refused at any future visit. Should this occur, I will need to inform the practice of this decision and sign another informed consent form, indicating my amended decision.

Yes No

The practice staff of Dr. J Viljoen Inc. are bound by the laws relating to patient confidentiality and will protect your personal and health information. We will not release your information without your written consent. A Consent to disclosure form can be obtained from the practice manager. I, the undersigned, being the patient/legal guardian of the patient hereby authorise the practice staff of Dr. J Viljoen Inc. to release personal and private health information to my medical aid scheme, other funders or any third party as directed by me. I consent to the sharing of any dental records and information including any treatment plans, prescriptions and other information pertaining to my care by this practice with other healthcare professionals involved in my treatment. I understand that these reports may contain personal and confidential information.

Yes No

I the undersigned, hereby give Dr J. Viljoen permission to do a clinical examination of myself / my child and to take the necessary radiology images or clinical photographs. After consultation with myself / my child and on his recommendation and my acceptance of his written cost estimate, I give my consent to Dr Viljoen to proceed with the necessary treatment or surgery. I confirm that the answers to the health questions are accurate and correct to the best of my knowledge. Since a change in a patient's medical condition or medication can affect Oral Surgery, I understand the importance of and agree to notify Dr Viljoen of any changes. I understand that I have the right not to disclose any of my private health information to any third party and that I could be treated on a strictly confidential basis. This will imply that I will be liable for the immediate settlement of all accounts and that I will take full responsibility for the disclosure of any information.

Yes No

Please note that this practice is not contracted in with any medical insurance. Billing codes are in line with the 2022 published South African Dental Association Tariff Guidelines. I understand that payment of services and goods rendered to me remains my responsibility. I agree to settle the full account within 30 days. If my account is not paid after 30 days, I will be given notice in terms of the National Credit Act. If I fail to settle the account within 60 days from the date or service, the account will be handed over for collection of debt to the legal firm Matthysen and Schulenburg Inc. I will be liable for all legal and collection charges, all administration costs and recovery fees.

Yes No

I give permission that the practice staff may contact me via services like mail, e-mail, SMS, WhatsApp, Signal and Telegram messages. I certify that my contact details are correct and undertake to inform the practice of any changes. I acknowledge and understand that despite recommendations that encryption software be used as a security mechanism for electronic communications, it is possible that communications with the Practice using the above services may not be encrypted. Despite this, I agree to communicate with the Practice’s staff, using these services, with a full understanding of the risk.

Yes No

I confirm that I can read and write the language in which this consent is drafted. I have read and fully understand its contents.

Yes No

Name and Surname

Date

manager@drjv.co.za

George Practice

Mossel Bay Practice

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