Patient Information PATIENT DETAILS Title Select your titleMrMrsMissMsMasterProfDr Surname* Full Names* Contact number* ID / Passport Number Date of Birth PERSON RESPONSIBLE FOR THE ACCOUNT Title Select your titleMrMrsMissMsMasterProfDr Surname Full Names Cell Number Email Employer Home Address Address Line 1 Address Line 2 City Postal Code Work Address Address Line 1 Address Line 2 City Postal Code Home Number Work Number Postal Address Address Line 2 City Address Line 2 Postal Code NEAREST FAMILY/EMERGENCYCONTACT Name Contact number MEDICAL AID DETAILS CONTACT Medical Aid Plan Dependent code Medical Aid Number Main Member Name Main Member ID Number HEALTH QUESTIONNAIRE Do you have or have you had any of the following illnesses: High/ low blood pressureAnginaRheumatic/scarlet feverCongenital heart diseaseAsthma/bronchitis/emphysema/TBJaundice/hepatitis/other liver diseaseKidney diseaseDiabetesEpilepsyBleeding tendencyAnemiaArthritisMuscular diseaseAllergiesOther Have you ever taken/ are currently taking any of the following medication Cortisone/ other steroidsAnti-depressantsTranquilizers/ sedativesAnti-coagulants/ blood thinnersBlood pressure/ anti-hypertensivesThyroid drugsContraceptivesBisphosphonate treatment / Bone densityOther Do you have any artificial prosthesis? (Heart valves/knees/hips) Have you or any family member had any complications or unusual reactions to local/general anesthesia? Female patients: are you pregnant/trying to get pregnant? I declare that the above information is correct and that I shall make known any changes in my health to the treating practitioner. I further declare that the above mentioned address is the account holders permanent address. I accept full responsibility for my account. I give consent to be treated by the dentist after consultation and with my full understanding of the treatment plan and costs thereof. This is a legal and binding contract. Name Signed Date Please leave this field empty.