Forms | ChrisGreeff

PATIENT DETAILS
Title*
FULL NAMES AND SURNAMES*
First Middle Last
Normally Called*
Gender*
- Male
- Female
ID Number
Language Preference*
- English
- Afrikaans
School Name (if applicable)
Grade (if applicable)
Referred By*
Your Dentist Name*
Your Dentist telephone Number

MEDICAL AID DETAILS
Scheme name*
Plan
Medical Aid Number*
Joining Date
Dependent Number (if applicable)
Full Name & Surname of Principal Member*
First Middle Last
Kindly note that - We do not deal with medical schemes. You are responsible to submit the account to your medical scheme. You are responsible to establish your orthodontic benefits from your medical aid. (Kindly refer to paragraph 3 of the financial policy)

DETAILS OF PERSON RESPONSIBLE FOR ACCOUNT
Title*
FULL Names and Surname*
First Middle Last
ID Number*
Home Phone*
Cell Phone*
Work Phone
Fax
Email*
Postal Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Residential Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Occupation
Employer
Way in which to receive correspondence*
- E-mail
- At Practice
Email*
Work Address*
Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country
Details of Spouse / Partner
First Middle Last
Spouse ID Number (if applicable)
Home Phone
Cell Phone*
Work Phone
Fax
Email*

PATIENTS SIGNIFICANT MEDICAL HISTORY
VERY IMPORTANT: Allergies, Heart Problems, Rheumatic Fever History, Diabetes, Epilepsy, Osteoporosis, Current Medication, Etc.*
(Please list all or any known allergies and/or illnesses. If unsure of any allergies and/or illnesses please write "None known"). Complete medical history form available at reception, if required.
Tonsils / Adenoids still present?
- Yes
- Removed
Reason for Seeking Treatment*
Have you had previous orthodontic treatment?*
- Yes
- No
If yes, who was the Dr treating you?

NEXT OF KIN
Not at the same address and telephone number - in case we cannot get hold of you confirming information.
Name*
First Last
Relationship to patient*
Home Phone
Cell Phone*
Signed at*
On this day*
Print Name*
Client confirmation*
- I confirm that the details provided are correct
Once submitted you will receive an email with this completed form. Please print, sign and bring with you on your appointment date. Please make sure you bring all your supporting documents as per this page: http://chrisgreeff.com/index.php/whattoexpect/
Important note on medical schemes
KINDLY NOTE THAT- WE DO NOT DEAL WITH MEDICAL SCHEMES ON YOUR BEHALF. YOU ARE RESPONSIBLE TO SUBMIT THE ACCOUNT TO YOUR MEDICAL SCHEME. YOU ARE ALSO RESPONSIBLE TO ESTABLISH YOUR ORTHODONTIC BENEFITS WITH YOUR MEDICAL AID (KINDLY REFER TO PARAGRAPH OF THE FINANCIAL POLICY)
Important note on Payment of account.
I, the undersigned, do hereby agree that: 1. Payment of the account in accordance with the tariff of charges prevailing in the practice shall be the responsibility of the undersigned/patient. 2. In the event of the account not being settled timeously and in full by the undersigned/patient and/or the relevant medical aid, interest will be charged at a rate of 2% per month on the outstanding balance until that amount is settled in full. 3. I hereby declare that I am the legal guardian/custodian of the above child and understand and accept the contract. 4. I undertake liability for all legal costs between attorney and client, as well as tracing and collection fees due. Should it be necessary to take legal action to recover and amount owing as a result of the treatment received by the above patient. 5 I further consent to your being entitled to obtain credit and related information concerning myself at any time and lodge, exchange and disclose such information with any Credit Bureau without any further notice to me.
Signature*
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PATIENT DETAILS

MEDICAL AID DETAILS

DETAILS OF PERSON RESPONSIBLE FOR ACCOUNT

PATIENTS SIGNIFICANT MEDICAL HISTORY

NEXT OF KIN

Important note on medical schemes

Important note on Payment of account.