PATIENT INFORMATION FORM AND FINANCIAL AGREEMENT CONTRACT

Kindly complete this form, which will become our office record and your financial agreement contract and will assist us in compiling a correct treatment plan
ALL INFORMATION WILL BE KEPT IN THE STRICTEST OF CONFIDENCE

PATIENT INFORMATION_ __

D D M M Y Y
TITLE: Surname: First Names: Date of Birth:

Home Address:

Work Address: Occupation:

Postal address:

Tel: (W) Tel: (H) Cell:

I.D Number : Email:

FINANCIALLY RESPONSIBLE PARTY INFORMATION __ IF NOT THE SAME AS ABOVE (RELATIONSHIP TO PATIENT:_______________________________)
D D M M Y Y
TITLE: Surname: First Names: Date of Birth:

Home Address:

Work Address: Occupation:

Postal address:

Tel: (W) Tel: (H) Cell:

I.D Number: Email:

MEDICAL AID______ _ IN ORDER FOR YOU TO CLAIM BACK FROM YOUR MEDICAL AID

Name of your Medical Aid Scheme: Medical Aid number:

Main Member NAME AND SURNAME:

DEPENDANTS________ _
Name Date of Birth Remarks

NEAREST FAMILY MEMBER / FRIEND BBBB

Name: Relationship:

Tel (H): Tel (W): Cell:

1. The practice is contracted out of medical aid and therefore does not limit itself to
NHRPL fees. I, (name) ………………………………………………………….
2. A description of the practice fee structure and a cost estimation will be prepared at any
time on request. HEREBY STATE THAT I FULLY UNDERSTAND ALL THE ABOVE
3. This practice is not a registered credit provider and may not extend credit. MENTIONDED FACTS AND AM AWARE THAT THIS IS A LEGAL
4. Fees are strictly payable after every visit. AND BINDING CONTRACT OF ARRANGEMENT BETWEEN
5. Appointment must be cancelled at least 6 HOURS before the time, otherwise a fee of
R400 per half hour will be charged.
JJS DENTISTRY AND MYSELF.
6. Should you have a genuine financial problem, please feel free to discuss this with us. SIGNED: …………………………………………………………….
7. Please inform us immediately of any changes in your address or patient details.
8. All accounts over 30 days will be charged 5% interest. DATE: ………………………………………………………….......
 Health Information
Referral Information
How did you first hear of our practice? Friend/Relative NAME:___________________ Internet Social Network Other:____________
Patient Name: ___________________________________________________ Birth Date: __________________________
Have you ever had any of the following? Please check those that apply:

□ Heart Valve Replacement □ Blood Disease □ Radiation Treatment

□ Infective Endocarditis (Heart Infection) □ Cancer □ Respiratory Problems
□ Congenital Heart Disease □ Crohn’s Disease □ Rheumatism
□ Repaired/Closed □ Diabetes □ Sinus Problems
Date___ /___ /___ □ Dizziness □ Sjogren’s Syndrome
□ Residual Defects □ Epilepsy □ Stomach Problems
□ Excessive Bleeding □ Stroke
□ Fainting □ Tuberculosis
□ Glaucoma □ Tumors
□ Heart Transplant □ Growths □ Ulcers
□ Heart Murmur □ Head Injuries □ Venereal Disease
□ Mitral Valve Prolapse □ Hepatitis □ Codeine Allergy
□ Other Heart Valve Disorder □ High Blood Pressure □ Penicillin Allergy
□ Heart Disease □ Jaundice □ Latex Allergy
□ Rheumatic Fever □ Kidney Disease □ Allergies ______________
□ Heart Surgery MM/YY___________ □ Liver Disease ______________
□ Chest Pain or Angina □ Mental Disorders □ OTHER:
□ Artificial Joints MM/YY __________ □ Nervous Disorders □ ______________________
□ Pacemaker
Type ______________________ □ ______________________
□ AIDS □ Pregnancy Due___________
□ Anemia
□ Arthritis
□ Asthma

• Name of Physician (G.P):____________________________________________ Phone: ____________________________________________

• Do you have any disease, condition or problem not listed here? ______
If yes, please explain: __________________________________________________________________________________________________
• Do you smoke or use smokeless tobacco? ______
If yes, what type and for how long: _______________________________________________________________________________________
• Have you ever had any complications following dental treatment? ______
If yes, please explain: __________________________________________________________________________________________________
• Have you ever had excessive bleeding requiring special treatment? ______
If yes, please explain: __________________________________________________________________________________________________
• Have you been admitted to hospital or needed emergency care during the past two years? ______
If yes, please explain: __________________________________________________________________________________________________
• Have you ever taken Bisphosphonate Medications? (normally used to treat Osteoporosis) ______
(Circle all that apply: Fosamax, Skelid, Didronel, Actonal, Boniva, Aredia, Zometa, Reclast, Other __________)
If yes, please list drug, dose and duration of use: _____________________________________________________________________________
• Are you now under the care of a physician? ______
If yes, please explain: ___________________________________________________________________________________________________
• Are you taking any drugs or medications (Prescription, Over the Counter)? (List Below) ______
Medication Name Dose Reason Medication Name Dose Reason
Warfarin
Antidepressants
Codeine (Disprin)
Cortisone
Ginko Biloba
St Johns Wort
To the best of my knowledge, all of the preceding answers and information provided are true and correct. If I ever have any change in my health, I
will inform the doctors at the next appointment without fail.

X ______________________________________________ Date: __________________________

Signature of Patient, parent or guardian
 Patient Name: _____________________________________________________________

Consent for Services

I consent to the diagnostic procedures and treatment by the dentist necessary for proper dental care.
I consent to the dentist’s use and disclosure of my records (or my child’s records) to carry out treatment, to obtain
payment, and for those activities and health care operations that are related to treatment or payment.
I authorize payment directly to the dentist or dental group of insurance benefits otherwise payable to me. I understand
that I am financially responsible for payment in full of all services rendered, regardless of what my medical aid or payer of
my dental benefits pays. By signing this statement, I acknowledge that I received a copy of the financial policy of this office
and I agree to the terms set forth in the policy.
All emergency dental services, or any dental services performed without previous financial arrangements, must be paid for
in cash at the time services are performed.
I grant my permission to you and your assignee, to telephone me at home or at my work to discuss matters related to this
form and my account.
I consent to the use of the provided email address(es) for appointment reminders and any other direct communication
from this office.

I have read the above conditions of treatment and payment and agree to their content.

X______________________________ Date: __________ Relationship to Patient: ____________________

Signature of patient, parent or guardian

Right to Revoke: You will have the right to revoke these Consents at any time by submitting to our office in writing, notice of your revocation. Please
understand that revocation of this Consent will not affect any action we took in reliance on this Consent before we received your revocation, and that
we may decline to treat you or to continue treating you if you revoke this Consent.
 DENTAL HEALTH QUESTIONNAIRE

Welcome to our practice. Please complete this Dental Health Questionnaire as completely as possible so that we can be prepared for your visit. Circle
“Yes” or “No” where indicated.
• What is your main reason for making this appointment?___________________________________________________________________________
• When was your last dental visit? _____________________________ Your last dental cleaning? ________________________________
• Do any of the following cause you discomfort? Hot? Yes - No Cold? Yes - No Sweets? Yes - No Chewing? Yes - No
• Do you have any difficulty chewing food on either side of your mouth? ………………………………………………………………………………………………….. Yes - No
• Do you have any digestive problems? ………………………………………………………………………………………………………………………………………………………. Yes - No
• Do you have any missing teeth? ………………………………………………………………………………………………………………………………………………………………… Yes - No
• Have your missing teeth ever been replaced? …………………………………………………………………………………………………………………………………………… Yes - No
If so, how? – Fixed Bridge -- Removable Partial -- Full Denture -- Dental Implant
• Do you have any loose teeth? …………………………………………………………………………………………………………………………………………………………………… Yes - No
• Do you have any cracked or broken teeth? ………………………………………………………………………………………………………………………………………………. Yes - No
• Do you do any of these more than once per day: Drink soda drinks? ………………………………………………………………………… Yes - No
Use breath mints? ………………………………………………………………………… Yes - No
Chew gum? ………………………………………………………………………………….. Yes - No
• Have you ever had a grinding appliance, guard, or any other treatment for your bite? ……………………………………………………………………………. Yes - No
• Do you ever clench of grind your teeth? …………………………………………………………………………………………………………………………………………………… Yes - No
• Do you ever have/or ever had any headaches? ………………………………………………………………………………………………………………………………………… Yes - No
• Do you ever have/ or ever had ear pain? …………………………………………………………………………………………………………………………………………………. Yes - No
• Do you ever have/or ever had tension, aching, or a tired feeling in you jaws? ………………………………………………………………………………………….. Yes - No
• Do you ever have/or have you ever had clicking or popping in your jaws or ears? …………………………………………………………………………………... Yes - No
• Have you ever had any gum problems? ……………………………………………………………………………………………………………………………………………………. Yes - No
• If yes, was it treated? ……………………………………………………………………………………………………………………………………………………………………………….. Yes - No
• Do/did your parents have dentures or gum disease? ……………………………………………………………………………………………………………………………….. Yes - No
• Do your gums bleed while brushing or flossing? ……………………………………………………………………………………………………………………………………….. Yes - No
• Do you floss your teeth more than 3 times per week? (Be honest – most don’t floss!) …………………………………………………………………………….. Yes - No
• Are you a smoker? ……………………………………………………………………………………………………………………………………………………………………………………. Yes - No
• Have you ever had orthodontic treatment? ………………………………………………………………………………………………………………………………………………. Yes - No
• Have you ever whitened (bleached) your teeth? ………………………………………………………………………………………………………………………………………. Yes - No
• Have you ever considered teeth whitening? ……………………………………………………………………………………………………………………………………………. Yes - No
• Are you unhappy with your smile? …………………………………………………………………………………………………………………………………………………………… Yes - No
If yes, what would you change: Straighten/get rid of spaces Yes - No
Whiten Yes - No
Make teeth Larger Yes - No
Make teeth Smaller Yes - No
Other: __________________________________________________
• Does dental treatment cause anxiety for you? …………………………………………………………………………………………………………………………………………... Yes - No
• Have you ever had an unpleasant experience at the dentist? …………………………………………………………………………………………………………………….. Yes - No
• Would you ever consider being sedated for dental treatment? …………………………………………………………………………………………………………………… Yes - No

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Patient’s Name Date Signature
 Financial Policy
This statement is to inform you of our financial policy. Your understanding of this policy is very important to us and will help us to facilitate
excellent service to you while maintaining our professional relationship. We are committed to helping you obtain and maintain optimum oral
health and aesthetics.

Patients without Medical Aid:

Full payment is due at the time of treatment

Patients with Medical Aid:

The patient portion and any deductible/co-payment will be due at the time of treatment.

• All charges you incur are your responsibility regardless of your medical coverage.
• We must emphasize that as your dental care provider, our relationship is with you, our patient, not with your medical aid
company. Your medical aid policy is a contract between you, your employer, and the medical aid company.
• Not all dental services are covered benefits in all contracts.
• We suggest and recommend treatment based on the need, not your medical aid coverage or eligibility.
• Regardless of being able to verify eligibility prior to treatment, you are still expected to pay in full at the time of service.
• Due to medical aid policies and companies differing greatly and being very complex we can only estimate, in good faith, your
coverage and patient portion of services.

WE ACCEPT THE FOLLOWING PAYMENT METHODS

• Cash
• Credit Cards
• Electronic Funds Transfer
• PAYPAL : paypal.me/jjsdentistry
• We do NOT accept Diners or AMEX Credit cards

Finance Charges
Unpaid balances will be subject to a 1 ½ % per month finance fee.

Our staff is always available to assist you with your financial and medical aid questions, which they will answer to the best of their
ability.

PAYMENT PLANS:
In certain cases, you may make financial arrangements by consulting with our office personnel prior to service. Prior to any payment
plans being instituted, at least one-third of the total amount due must be paid.

MINOR PATIENTS:
The adult accompanying a minor and the parents (or guardian of the minor) are responsible for full payment. For unaccompanied
minors, non-emergency treatment will be denied unless charges have been pre-authorized to an approved credit card, or payment by cash
at time of service has been verified.

MISSED APPOINTMENTS:
Unless cancelled at least 6 hours in advance, during business hours, a charge of R400 per half hour scheduled appointment will be
allocated to your account (min R400). Please help us serve you better by keeping scheduled appointments.