Patient Registration Form

Date of Birth

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Female

Married Single Divorced Widowed

Patient

Next of Kin

To Bill

Email

Phone

SMS

Billing Preference

Next of Kin

Self

Other (Specify)

Being treated?

Pregnant?

Been hospitalised?

Do you have any of the following

Heart Disease

Tuberculosis

Rheumatic Fever

Shortness of Breath

Diabetes

Veneral Diseases

Bleeding Disease

Epilepsy Convulsions

High/ Low BP

Allergies

Kidney Disease/ Infection

Liver Disease/ Hepatitis/ Jaundice

HIV

Acknowledgement of Debt

(To be completed once only)

At The Smile Clinic, we are committed to doing everything within our power to recover claims from your medical aid for the services provided to you. However, there are circumstances where the medical aid may not honour the claims despite our diligent efforts.

I acknowledge and agree to settle in full, immediately, all amounts owed to The Smile Clinic if any of the following occurs:

1.The medical aid refuses to honour the claim.
2.Shortfalls arise due to non-payment or exclusion of certain procedures.
3.The medical aid exceeds 90 days without paying the submitted claim.
4.The medical aid fails to pay for any other reason not mentioned above.

By signing below, I acknowledge having read and accepted the above.

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