New Patient Registration Form

Dr. Christa Engelbrecht Dental

 

New Patient form

New Patient registration and Medical History

"*" indicates required fields

Personal Details

Name*
MM slash DD slash YYYY
Address*
Please include the following: Main Member, Main Member ID Number, Scheme, Medical Aid number
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?
Are you taking any medicines from your doctor? (tablets, creams, injections, other)
Are you taking or have you taken steroids in the last two years?
Are you allergic to any medicines, foods or materials?
Have you had Rheumatic fever or Chorea?
Have you had jaundice, liver disease, kidney disease or hepatitis?
Have you ever been told you have a heart murmur or heart problem, angina, blood pressure, heart attack?
Have you had any infectious diseases (including hepatitis and HIV)?
Have you had a bad reaction to general or local anaesthetic?
Have you been hospitalised? IF YES what for and when?
Do you have a hip, knee or any other joint replacement?
Do you have a pacemaker, or have you had any form of heart surgery?
Do you suffer from hayfever, eczema or any other allergy?
Do you suffer from bronchitis, asthma or any other chest condition?
Have you ever fainted, get blackouts or suffer from epilepsy?
Do you or any member of your family suffer from diabetes?
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?
Do you carry a warning card?
Do you ever get cold sores?
Do you smoke any tobacco products now (did you in the past?) IF YES, how many per day?
If you were referred by a friend, please note the name as we will reward them with a R100 'REFER A FRIEND' voucher.

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.

Clear Signature
MM slash DD slash YYYY
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