New Patient Form - Adult ⋆ Wiggly Teeth

patient details

Full name

ID number

Cell phone

Date of Birth

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

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.

Submit

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