onepager – UDENT Dental Solutions

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PATIENT DETAILS

Patient Name

Patient Last Name

Patient Date of Birth:

Year

Month

Day

ID - Please enter the Patient ID#

Patient Email

Patient Primary Contact Number

Patient Alternative Contact Number

Referred by

Referred by Contact Number

Patient Allergies

PERSON RESPONSIBLE FOR ACCOUNT

Accounts Person First Name

Accounts Person Last Name

ID - Please enter the ID# for person responsible for account payment

Primary Contact Number

Alternative Contact Number

Accounts Email

Home address of person responsible for accounts

Postal address of person responsible for accounts

NEXT OF KIN (FAMILY/FRIENDS)

In case of emergency

Next of Kin First Name

Next of Kin Last Name

Next of Kin Contact Number

MEDICAL AID CLAIMS

I understand that:

The responsibility for confirming funds and obtaining authorization for treatment lies with the patient. Ask for a quotation if you wish to confirm available funds and/or procedures covered. A Dental examination (x-rays at an additional charge) is required before any quotations can be made.

Please complete if a Medical Aid should be invoiced

Yes please, I accept the following Terms & Conditions:

Medial Aid Main Member ID

Name of Medical Aid

Medical Aid Number

Plan

Main member

Dependant Code

Take a photo or Upload a photo of the FRONT of your medical aid membership card

Choose File

Take a photo or Upload a photo of the BACK of your medical aid membership card

Choose File

Upload (if provided) your virtual, medical aid card

Choose File

Alternative:

Please WhatsApp a front and back photo of your medical aid card or forward your virtual card to 076 917 4857

Permission to process personal information

For the purpose of this Agreement, the terms personal information, data subject, processing, responsible party and operator are defined as set out in the Protection of Personal Information Act (POPIA).

I, the Client/Parent/Legal Guardian, the duly appointed representative of the Client, hereby agree that UDENT Dental Solutions may process all personal information related to the company for lawful business reasons, operations and activities of UDENT Dental Solutions. Types of information will depend on the purpose of the data collection, and will only be processed for the intended purpose.

Wherever possible, all personal information will be processed by UDENT Dental Solutions (as the responsible party). However, the company further agrees that UDENT Dental Solutions may contract with other organisations to provide support services as suppliers to UDENT Dental Solutions, and in the course of their work, may process personal information of the company. UDENT Dental Solutions will legally bind all service providers to its privacy policy in their access and processing of any personal information of the company.

Purpose of the processing of personal information:
We would like to clarify how, and for which purpose we will be processing your personal
information. We mainly collect, store, use and make available your personal information in order to give you access to the services and products of UDENT Dental Solutions.
We will only process your information for a purpose that you reasonably would expect, including the following:
• To provide you with advice, products and services that you have requested;
• To verify your identity and to confirm credit referrals;
• To organise, administer and manage logistical functions;
• To notify you of new products or developments that may be of interest to you;
• To verify or update your personal details;
• To receive payment from you for goods or services rendered;
• To act in the lawful interest of UDENT Dental Solutions;
• To meet any legal or legislative duties imposed upon UDENT Dental Solutions.

You have the following rights:
• The right to know what personal information we store, how such information is processed, and under which conditions UDENT Dental Solutions make such information available.
• The right to correct or update your personal information.
• The right to withdraw this permission related to your personal information.

Should you believe that your personal information is not being processed correctly, or that
your personal information is used for a purpose not originally intended, please contact our
Information Officer:

Information Officer: Dr Hanco Blignaut
E-MAIL: admin@udent.co.za

Signed at:

By checking this box, I confirm that:

All information provided is accurate & I agree to the Terms & Conditions

Draw your signature into the box below.

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