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Services
Blog
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New patient

1

Patient Details

2

Medical history

3

Main member of medical aid / Person responsible for account

patient details

Full name

ID number

Cell phone

Date of Birth

Medical History

Name of family doctor and contact details

Is the patient under supervision for any medical condition?

Yes No

Specify

Is the patient in good health?

Yes No

Specify

Is the patient on any chronic medication?

Yes No

Specify

Any Allergies

Yes No

Specify

Have the patient's adenoids/ tonsils been removed? Please specify any other surgeries or hospitalizations.

Please indicate if the patient has any of the following:

Rheumatic fever Anaemia Bone disorder HIV positive Diabetes Epilepsy/ Seizures Bleeding disorders TB Endocrine disorders Cleft palate Asthma Liver problems/ Hepatitis Cancer/ leukaemia Speech problems ADHD Cardiac problems/ heart murmurs Other

Pregnant?

Yes No

How many weeks?

Physical Handicap

Yes No

Specify

Mental handicap

Yes No

Specify

other

Yes No

Specify

Main member of medical aid / Person responsible for account

Full name

ID number

Postal Address

Home phone

Cell phone

Email address

Medical Aid

Yes No

Medical Aid name

Medical Aid number

Option

Nearest relative/ friend name

Contact number

Do you have a booking?

Yes No

Please specify Doctor:

Date

Time

I understand that the above information is accurate.

I understand the above and comply with the conditions of Wiggly Teeth.

We are a private practice. The account needs to be settled in the rooms after each appointment. A major portion can be claimed back from the medical aid by member. We don’t claim from medical aid.

I do herby authorize and consent to the use of photographs of my / my childs’ teeth taken by Wiggly Teeth Dentistry. I grant them permission make use of photographs taken of me / my child for marketing material for website, social media and/or educational purposes.

Yes No

I further understand that if the photography is used that my / my childs’ name and or other identifying information will not be used. No full-face images will be used.

Yes No

I further acknowledge my participation in voluntary and that I will not receive any compensation, financial or otherwise, with respect to the taking, use or publication of these images. I acknowledge and agree that these images confer no rights of ownership or royalties whatsoever.

Yes No

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Contacts

+27 12 347 0718
info@wigglyteeth.co.za
Cure Day Hospital - Erasmuskloof, Room 202, 506 Jochemus Street, Erasmuskloof Ext 3. Pretoria, 0153
Contact Account, Screening or Theatre

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