Patient Information & Medical History

Please complete this form ahead of your visit. It helps us provide you with the safest and best possible care. Fields marked * are required.

Patient Details
Contact Details
Preferred Contact
Referral Information

How did you hear about us?

Account & Medical Aid
Have you or any dependants on this medical aid visited our practice before?
Patient Medical History

Have you ever been diagnosed with any of the following? (Tick all that apply)

Medications

Are you currently taking any medications, vitamins or supplements?
Are you taking any blood-thinning medication?

Allergies

Do you have any allergies? (Tick all that apply)

Lifestyle
Do you smoke or vape?
Do you consume alcohol?
Dental-Specific Health

Have you ever experienced any of the following? (Tick all that apply)

Medical Alerts

Appointment Information & Past Experience

I am visiting the dentist for (tick all that apply)

General Dental Information

Do your gums bleed when brushing / flossing?
Does food / floss catch between your teeth?
Patient Declaration & POPIA Consent

I confirm that the information supplied is true and complete to the best of my knowledge. I consent to the collection and processing of my personal information for treatment, administration and communication purposes in accordance with POPIA.

Peacedent (hereinafter referred to as "doctor") of 1 Messer Street, Tzaneen, 0850. Practice Code No: 0559539.

Agreement — the responsible person hereby agrees as follows:

  1. That (s)he is liable for medication supplied by the doctor, the Patient and all dependants and, to the extent that it is applicable. (S)he is the parent/legal guardian of the person to whom the services were rendered.
  2. To pay promptly the account of the doctor in accordance with the tariff of charges prevailing in the doctor's practice, or as agreed upon between the parties, and in the manner in which the parties have agreed.
  3. To settle the doctor's account timely and in full, as agreed, irrespective of contracts/agreements/arrangements (s)he may have with any medical scheme or any third party.
  4. Should the account not be settled in full within 20 business days after the services were rendered by the doctor, interest will thereafter be charged on any outstanding amount at a rate of 2% per month until the date that the account is settled in full.
  5. Should the doctor institute legal action against the responsible person for recovery of any outstanding debts, to pay all legal costs including attorney and own client costs, collection fees and tracing fees;
  6. It is acknowledged that, in accordance with the provisions of Section 53 (1) of the Health Professions Act of 1974 (duly amended) and Section 6 (c) of the National Health Act 61 of 2003, the costs associated with all medical services rendered by the doctor, treatment and/or procedures have been discussed and were fully explained to the responsible person and/or patient, to the extent required in law and professional ethics;
  7. In accordance with legal requirements (POPIA) the doctor is granted permission to disclose any information about the responsible person and/or the patient, including medical information and/or diagnosis or diagnostic codes, to relevant third parties (such as funders, administrators, switching companies, prescription pharmacies and the like) for purposes of processing payment of accounts in respect of medicines dispensed and/or medical services rendered to the responsible person/the patient; as required by a specific Act or statute, professional ethics or formal policy of directive applicable to the situation. The responsible person and/or patient have been informed that, in certain circumstances, such as disclosure of ICD-10 codes, the exact consequences of disclosing such information is unknown to the doctor and that information relating to these consequences must be obtained by responsible person and/or patient from the third party to whom the information is disclosed.
  8. The responsible person and/or patient agree that the doctor may:
    1. Make enquiries to confirm any information provided by the responsible person and/or patient;
    2. Seek information from any credit bureau when assessing the responsible person and/or patient's application for credit, or at any time during his/her continuing indebtedness to the doctor including tracing or confirming his/her whereabouts;
    3. Disclose the existence of his/her account to any credit bureau, sharing both positive and negative payment information about such account.
  9. The responsible person and/or patient furthermore, agree that the doctor will be entitled to obtain and disclose the above information:
    • if the doctor considers that it is necessary or may be of benefit to the responsible person and/or patient;
    • where the doctor is under a legal obligation to do so;
    • where it is in the doctor's own or the public interest that he/she does so.

Fields marked * are required. Your information is kept confidential.

Have a question before your visit?

Our reception team is available Monday to Friday, 8 am to 5 pm.

015 307 3789 WhatsApp Us