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Removal of silver fillings
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Home
Our Services
Adult Orthodontics / Clearcorrect
Smile Makeover
Treatment for headaches
Nervous patients
Children’s Orthodontics / Myobrace
Teeth whitening
Dental Treatment
Mouthguards
Families
Implants
Crowns
Root canal treatment
Removal of silver fillings
Oral Hygiene
Clearcorrect
Smile Gallery
Adult Orthodontics / Clearcorrect
Children’s Orthodontics / Myobrace
Composite Bonding
Dental Implants
Smile Makeovers
Tooth Whitening
About Us
Blog
Contact Us
Online Booking
Existing Patient Records update
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Existing Patient Records update
Dr. Christa Engelbrecht Dental
Existing Patient Records update
Name
Mr
Mrs
Miss
Ms
Dr
Prof.
Rev.
Prefix
First
Last
Date of Birth
MM slash DD slash YYYY
Email
Please note any changes to your contact details
Please note any changes to your Account information
Please note changes to medical aid or person responsible for account here.
Please note any changes to your Medical History
Please note changes to history, any hospitalisation, medications taken and allergies
Consent
*
I agree to the privacy policy.
Privacy Policy
What information do we collect?
We may collect the following kinds of information about you:
• Personal details such as your name, date of birth, gender, ID, address, telephone number, email address, occupation
• Information about your dental and general health, including clinical records made by dentists and other dental professionals involved with your care and treatment
• X-rays, clinical photographs, digital scans of your mouth and teeth, and study models
• Medical and dental histories
• Treatment plans and consent
• Notes of conversations with you about your care
• Correspondence from other health professionals or institutions involved in your care
• Details of the fees we have charged, the amounts you have paid and some payment details
• Feedback and complaints
How we obtain information
You may give us information about you through the following:
• Filling in forms at our practices or on our websites.
• Corresponding with us by phone, e-mail or otherwise.
• Through the technology you use to access our services
cookies from your browser.
How we use your information – the purpose
We may use this information to:
• To provide you with the dental care and treatment that you need, we require up-to-date and accurate information about you.
• We may contact you to conduct patient surveys or to find out if you are happy with the treatment you received for quality control purposes.
• We will seek your preference for how we contact you about your dental care. Our usual methods are SMS, telephone, email or letter.
• We may use your information for our own analysis to understand the effectiveness of our marketing activities.
If we wish to use your information for dental research or dental education, we will discuss this with you and seek your consent. Depending on the purpose and if possible, we will anonymise your information. If this is not possible we will inform you and discuss your options.
We may use your contact details to inform you of products and services available at our practices.
Sharing your information
Your information is normally used only by those working at the practice but there may be instances where we need to share it – for example, with:
• Your doctor
• The hospital or community dental services or other health professionals caring for you
• Dental laboratories
• Private medical schemes of which you are a member
• Debt collection companies
We also share your information with third parties in order to deliver the following services to you:
• Managing new enquiries from our website
• Contacting you to check if you wish to remain a client of ours
• Sending reminders for your dental appointments
• Sending you our practice newsletter
• Processing on-line booking appointments
• Collecting feedback from our patients
• Managing email communications to our patients
• Providing troubleshooting and support services for our various IT systems
We will only disclose your information on a need-to-know basis and will limit any information that we share to the minimum necessary. We also have third party agreements in place to protect your information.
How we will keep your information safe
We employ administrative, electronic and physical security measures to ensure that the information that we collect about you is protected from access by unauthorised persons and protected against unlawful processing, accidental loss, destruction and damage.
This includes:
• Password protection
• Locked cabinets/rooms
• Practice security systems
• Virus protection
• Secure servers
• Back-up facilities
• Secure cloud-based storage
How long will we keep your information?
We keep your dental records for 10 years after the date of your last visit.
Your rights
Access
You have a right to access the information that we hold about you and to receive a copy. You can make a request by contacting your practice or by e-mailing info@drchristaengelbrecht.com
Rectification
You have a right to correct any information that you believe is inaccurate or incomplete. Please contact your practice to request a change in information.
Erasure
You have a right to request that we delete your personal information, although you should be aware that, for legal reasons, we may be unable to erase certain information (for example, information about your dental treatment).
Restriction
You have the right to request us to restrict the processing of your personal information for example, sending you reminders for appointments or information about our service. Please contact us to make this request.
Portability
You have a right to data portability, this could include supplying your information to another dentist. Please contact us to make this request.
Consent
*
I agree to the payment policy.
I understand and agree that I am responsible for the balance on my account for any professional services rendered. I understand and agree that it is my responsibility that the account reaches my medical aid in time. I understand that all accounts should be settled on the day of treatment and I agree that bank rate interest will be charged on all accounts older than 60 days and accounts older than 90 days will be amended to a higher rate and sent to debt collectors.
I hereby certify the information on the Patient Information Form to be true and correct to the best of my knowledge. I will notify Dr Christa Engelbrecht Dental in the event of any changes in my health status or any changes in the above information.
Signature
*
Date
MM slash DD slash YYYY
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