Patient Information:
Emergency Contact:
Medical Aid Information:(If you have medical aid, please complete the details below to claim reimbursement.)
Medical History:
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Declaration and Practice Terms
I acknowledge that Smile Solutions Dental is a private practice and does not participate in medical aid schemes. I accept responsibility for the practice’s fees, declare that the information I have provided is true and correct, and confirm that I have read and agree to the Patient Agreement and Terms.
POPIA Privacy Acknowledgement
I confirm that I have read and understood the POPIA Privacy Notice and understand how my personal information, including health information, will be collected, used, stored and shared for the purposes described in the notice.
[Read the POPIA Privacy Notice]