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
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Acknowledgment of patient information form
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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 - Consent for Use of Private Information
I the undersigned
(FULL NAMES AND SURNAME)
, ID/Passport:
(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 and does not submit accounts on the patient behalf.
The quotation only provides a cost estimate; the final treatment plan and costs may differ.
Final laboratory and component fees may differ due to fluctuations in exchange rates and material costs.
The practice charges fees that are above the National Health Reference Price List (NHRPL).
The cost estimate excludes surgical fees and fees of any other practitioners involved.
Cost estimates are valid for the calendar year in which they were generated.
After completion of treatment, the patient will be placed on a maintenance program (not included in estimate).
Any disputes will be handled by the 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.
I agree to pay all legal charges on the attorney and client scale including collection commission should legal action be instituted.
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:
