New Patient Registration Form

Personal Details

Name*

Prefix First Last

Date of Birth*

ID Number / Passport number

Address*

Street Address Address Line 2 City ZIP / Postal Code Country

Email*

Phone*

Mobile*

Next of Kin Name and Contact number

Doctor Name and Contact number

Medical Aid Details

Please include the following: Main Member, Main Member ID Number, Scheme, Medical Aid number

Account Details

Please include the following: Person responsible for account, ID number, Home address, Email address, Contact Number

Confidential Medical History

Are you attending or receiving treatment from a doctor, hospital, clinic or specialist?

Yes
No

Details

Are you taking any medicines from your doctor? (tablets, creams, injections, other)

Yes
No

Details

Are you taking or have you taken steroids in the last two years?

Yes
No

Details

Are you allergic to any medicines, foods or materials?

Yes
No

Details

Have you had Rheumatic fever or Chorea?

Yes
No

Details

Have you had jaundice, liver disease, kidney disease or hepatitis?

Yes
No

Details

Have you ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack?

Yes
No

Details

Have you had any infectious diseases (including hepatitis and HIV)?

Yes
No

Details

Have you had a bad reaction to general or local anaesthetic?

Yes
No

Details

Have you been hospitalised? IF YES what for and when?

Yes
No

Details

Do you have a hip, knee or any other joint replacement?

Yes
No

Details

Do you have a pacemaker, or have you had any form of heart surgery?

Yes
No

Details

Do you suffer from hayfever, eczema or any other allergy?

Yes
No

Details

Do you suffer from bronchitis, asthma or any other chest condition?

Yes
No

Details

Have you ever fainted, get blackouts or suffer from epilepsy?

Yes
No

Details

Do you or any member of your family suffer from diabetes?

Yes
No

Details

Do you bruise easily or following tooth extraction, surgery or injury have you or your family bled so as to cause you to be worried?

Yes
No

Details

Do you carry a warning card?

Yes
No

Details

Do you ever get cold sores?

Yes
No

Details

How many units of alcohol do you drink per week?

Do you smoke any tobacco products now (did you in the past?) IF YES, how many per day?

Yes
No

Details

Are there any other aspects concerning your health that you think the dentist should know about?

Are you anxious or nervous about your dental treatment?

Please rate your satisfaction with your smile on a scale from 1 - 5 if 1 is very poor and 5 is excellent?

What improvements (if any) would you like to make to your dental appearance / smile?

How did you hear about us?

If you were referred by a friend, please note the name as we will reward them with a R100 'REFER A FRIEND' voucher.

Privacy Policy 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.

Payment Terms 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 if I wish to be reimbursed by my fund. 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

CAPTCHA

Dr. Christa Engelbrecht Dental

New Patient form

Personal Details

Confidential Medical History

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.

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