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Person Responsible for Account
Medical Aid
Nearest Family

Referred By
Family Details


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NB: Please be advised that your results will differ from the advertisement as it is only a product marketing tool.

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1. ILLNESSES: (Do you have or have you had any of the following)
2. PREVIOUS OPERATIONS: (Specify)
3. MEDICATIONS: (Are you taking or have you taken)
FEMALE PATIENTS

Please verify this information at each visit as it is important when taking X - rays and when prescribing antibiotics.
DECLARATION: I declare tha t t h e above mentioned information is correct and that I shall make known any ch anges in my health to the treating doctor. I further declare that the abov e - mentioned address is the account hol der ’s permanent address ( domicilium citandi et executandi ). I accept responsibility for my account. If my account is not settled in full before 60 days, I take full response to settle all outstanding balances. I give consent to be treated by a dentist after consultation and with my full understanding the treatment plan. This is a legal and binding contract.

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