Patient Details
*
Full Names:
*
Surname:
Dependant No:
Nick Name:
*
Date of Birth:
*
Gender:
*
Home Address:
*
City:
*
Province:
EC
FS
GT
NL
LP
MP
NC
NW
WC
*
Postal Code:
Area Code:
Home Tel:
Patient Cell Number:
ID Number:
Cell number for appointments:
Grade in school:
School:
Person completing this form (Name and Surname):
Relation to Patient:
Mother
Father
Guardian
Other
Other Relation:
Person Responsible For Account
*
Full Names:
*
Surname:
Title:
Mr
Mrs
Ms
Dr
Prof
Other
Marital Status:
ID Number:
Home Language:
*
Postal Address:
*
City:
*
Province:
EC
FS
GT
NL
LP
MP
NC
NW
WC
*
Postal Code:
*
Home Tel:
Cell:
Employer Name and Number:
Occupation:
Phone:
*
E-mail Address for Correspondence with Treatment and Account:
Please indicate if any family member is undergoing orthodontic treatment:
Medical Aid Details (as per medical aid card)
Medical Aid Name:
Membership Number:
Dependent Number Details:
Main Member:
Nearest Family/Friend
Name and Surname:
Relation to Patient:
Tel No :
Medical History of Patient
Name of Physician:
Do you have any health problems? If yes, explain:
Please List:
Any allergies?
Are you taking any medication?
Please Indicate:
Heart problems
Yes
No
Blood transfusions
Yes
No
Hepatitis
Yes
No
Arthritis
Yes
No
Cancer
Yes
No
Liver disease
Yes
No
Diabetes
Yes
No
Kidney disease
Yes
No
Cerebral Palsy
Yes
No
Asthma
Yes
No
Problems with birth
Yes
No
Rheumatic fever
Yes
No
Cleft lip and/or palate
Yes
No
Speech and/or hearing problems
Yes
No
Sleep and/or snoring problems
Yes
No
AIDS or HIV
Yes
No
Tonsils and/or adenoid problems
Yes
No
Dental History
What is your main concern about your dental status?
How often do you visit your dentist?
6 Months
Yearly
2-Yearly
Sporadic
Your dentist's name:
Do you currently have dental pain?
Yes
No
Have you inherited any family facial and/or dental characteristics?
Yes
No
Have you or do you still suck a thumb and/or finger?
Yes
No
I the undersigned, being duly authorized hereto, confirm all the stipulations and conditions herein and on the reverse hereof.