Westrand Dental Centre | New Patients

Welcome to Westrand Dental Centre!

If you’ve decided to begin your dental care journey with Westrand Dental Centre in Roodepoort, we can’t wait to meet you. Before your first appointment, we invite you to take advantage of the new patient forms we’ve provided here for your convenience. You can download it, print it out, and fill it out before coming to our office or you can fill it in online. We know your time is valuable – we try to offer ways to save it.

New Patient Registration Forms (Download)
New Patient Registration Forms (Online, below)

Our payment options include Medical Aid, cash, MasterCard, and Visa. Our office staff will submit your dental claims and make every effort to maximize your benefits. Value is one of our commitments, and making dental care affordable for everyone.

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New Patient Registration Online Form:

Patient Details:

Title:
Surname:
Full Names:
Gender:	Male Female
Date of Birth:
Who refered you to this Practise?
Residential Address:
Work Address:
Postal Address:
Tel (Home):
Tel (Work):
Tel (Cell):
Tel (Fax):
Email Address:

Medical Aid Details:

Name:
Scheme:
Number:
Option:

Person responsible for account:

Same as above
Title:
Surname:
Full Names:
Gender:	Male Female
ID Number:
Who refered you to this Practise?
Residential Address:
Work Address:
Postal Address:
Tel (Home):
Tel (Work):
Tel (Cell):
Tel (Fax):
Email Address:

Contact number of friend or relative:

Name:
Relation to Main Member:
Tel (Home):
Tel (Work):
Tel (Cell):

Medical History:

Declaration:

I declare that all information above is correct, and that I am responsible for the payment of any accounts until, or if not, settled by the medical Aid.

Any accounts older than 120 days will be handed over to our attorneys for collection.

I accept the term and condition.

Security Code

Enter Security Code:

Not readable? Change text.

Rheumatic Fever	Sinus	Diabetes
Epilepsy	Blood Pressure (high or low)	Asthma
Smoking	Clotting Problems	Aneamia
Pregnant	Heart Condition	Are you taking Cortisone?
Abnormal reaction to dental injections	Do your gums bleed?	Do you suffer from frequent Ulcers?
Any loose Teeth?	Bad Breath	Do you grind or clench?
Pain in the joints of your Jaw?	Any previous Dental operations?	Orthodontic treatment
Have you been shown how to brush your teeth?
Allergies:
Are you currently more tense?	Yes No
Current Medication?	Yes No
If Yes, Please spesify:

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