Patient Information

PATIENT DETAILS

Title

Surname (required)

Full Names (required)

Initials (required)

ID / Passport Number

Date of Birth

Gender

Marital Satus

Employment Satus

Description

ADDRESS

Home Address

Address Line 1

Address Line 2

City

Postal Code

Postal Address

Address Line 1

Address Line 2

City

Postal Code

CONTACT INFORMATION

Home Number

Work Number

Cell Number

Email

Preferred Contact Method

REFERRAL

Reffered by

Referral name

PERSON RESPONSIBLE FOR ACCOUNT

Medical Aid

Medical Aid Plan

Medical Aid Number

Main Member Name

Main Member ID Number

APPOINTMENT INFORMATION

Purpose of visit

Past Experience

PREVIOUS MEDICAL HISTORY

HAVE YOU HAD OR HAVE ANY OF THE FOLLOWING

Do you smoke(including E-cigarettes)

How many per day

PRE-EXISTING CONDITIONS

DO YOU HAVE ANY OF THESE PRE-EXISTING CONDITIONS

Name of treating physician

Contact Number

Are you pregnant or breastfeeding?

Are you allergic to latex?

Have you ever had a bad reaction to local anaesthetics?

Please list any drug allergies

Please list any medication you are currently taking at the moment

Any other conditions that you think we need to be aware of

GENERAL DENTAL INFORMATION

Last Visit To a Dentist

Last Dental Cleaning

Last Dental X-rays Taken

Last Dentist

DENTAL HABITS

How often do you brush your Teeth?

How often do you floss?

Do your gums bleed when you brush or floss?

Does food or floss catch between your teeth?

Fee structure for the practice

This practice is contracted out of medical aid and therefore does not claim from any medical aid. The patient is responsible for the full account, which has to be settled immediately after the appointment.

Contact Us

  • Address: Newlands on Main | Piazza Level | Letterstedt House| Main Road | Newlands

  • Phone: +27 21 671 1504

  • Email: info@cornesmith.co.za