BChD (Stell), Dip Odont (Aest) (Pret), MSc (Wits), MChD (UWC)
Practice number: 094000 0501158 | Practice Telephone: 021 671 2562
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Practice number: 094000 0501158 | Tel: 021 671 2562
Medical Conditions
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Practice number: 094000 0501158 | Tel: 021 671 2562
Medical History
Have you been under a physician's care or hospitalized during the last two years?
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Acknowledgment of patient information form
I agree to allow you to use my testimonial, photos, videos, and name for educational or marketing purposes.
By signing below I am verifying that all information on this form is accurate and current.
Dated at
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(PLACE) (DAY 1–31)(MONTH 1–12) (YEAR)
⚠️ Patient is a MINOR — Parent or Guardian must sign below
X Signature of patient or guardian (if the patient is a minor):
DR A.A. GRUNDLINGH
BChD (Stell), Dip Odont (Aest) (Pret), MSc (Wits), MChD (UWC)
Practice number: 094000 0501158 | Practice Telephone Number: 0216712562
POPI ACT: APPROVAL FOR ACCESS, USE AND PROCESSING OF PRIVATE INFORMATION
I the undersigned
(FULL NAMES AND SURNAME)
(ID/PASSPORT NUMBER)
Give my consent that my personal information can be shared with referring clinicians and debt collectors of the practice accounts.
Dated at
on this
day of
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(PLACE) (DAY 1–31)(MONTH 1–12) (YEAR)
⚠️ Patient is a MINOR — Parent or Guardian must sign below
X Signature of patient or guardian (if the patient is a minor):
DR A.A. GRUNDLINGH
BChD (Stell), Dip Odont (Aest) (Pret), MSc (Wits), MChD (UWC)
Practice number: 094000 0501158 | Practice Telephone Number: 0216712562
ACCOUNTS LIABILITY
All treatment costs due are payable by the patient on or before the commencement of treatment.
The final treatment costs are payable before the placement of the permanent crowns, bridges, or prostheses.
The practice is not affiliated with any medical aid scheme or fund and therefore does not submit accounts on the patient's behalf. Submission of accounts to medical aid schemes or funds for authorisation and reimbursements will be the responsibility of the patient.
The quotation only provides details pertaining to the cost estimate of the proposed treatment. The final treatment plan and costs may differ from the proposed treatment, as every treatment is determined by the clinical circumstance. This will however be discussed with the patient.
Final laboratory fees and component fees may differ from the amounts in the cost estimate due to fluctuations in exchange rates and material costs, due to changes in the use of materials and components during manufacturing of the prosthesis or due to changes in the treatment.
The practice charges fees that are above the National Health Reference Price List (NHRPL).
The cost estimate excludes the surgical fees and the fees of any other practitioners involved in your treatment. The surgeon/practitioner involved will provide the cost estimate of any treatment to be undertaken by them.
Cost estimates are valid for the calendar year in which it was generated. Procedures done and paid for in the following year will carry the associated increase for the new year.
After completion of the treatment, you will be placed on a specifically prepared maintenance program. This cost is not included in the cost estimate.
Any disputes will be handled in South Africa by Health Professionals Council of South Africa (HPCSA)
*I hereby acknowledge and agree that by my signature below I will be held liable for the due payment of all amounts which may now or at any time hereafter become payable.
*I agree to pay all legal charges on the attorney and client scale including collection commission should legal action be instituted against me.
Dated at
on this
day of
/
(PLACE) (DAY 1–31)(MONTH 1–12) (YEAR)
⚠️ Patient is a MINOR — Parent or Guardian must sign below
X Signature of patient or guardian (if minor):
X Signature of person responsible for payment of account:
