About You

Account Holder

Insurance Information

Medical History

Do you or have you experienced any of the following?

Abnormal BleedingAnaemiaArtificial Bones/JointsArtificial ValvesAsthmaAnginaBreathing ProblemsCancerCold sore/Fever BlistersDiabetesDepressive IllnessEmphysemaEpilepsy/SeizuresFainting SpellsGlaucomaHeadachesHeart DisorderHay feverHaemophiliaHepatitisHerpesHigh Blood PressureHIV+/AIDSKidney ProblemsLung DiseaseLiver DiseaseLupusOsteoporosisPacemakerPain in Jaw JointsRheumatic FeverSeizuresSinus TroubleIntestinal DiseaseStrokeTobacco Use (Smoke)Tuberculosis (TB)TumoursUlcers

Please list any serious medical condition(s) that you have experienced:

Please list any medications you are currently taking:

Any Allergies that you are aware of?

For Women:
Are you Pregnant?

Where did you hear about us?

dentist somerset west

New Patient Information

We know your time is worth a lot. If you prefer, you can download and complete the patient intake form at home and email to smile@matheedentalstudio.co.za or please bring it along for your first appointment. You are also welcome to complete it at our office.

~ Johan Mathee

Download Patient Intake Form

PAYMENT POLICY

Full payment is required on the day of each treatment.

Payment options:
Cash, Credit Card, Debit Card or an Internet transfer before your appointment.

If an Internet transfer is made, please send your proof of payment to:
smile@matheedentalstudio.co.za before the appointment.

Mathee Dental Studio’s banking details are:
Absa Private Bank Stellenbosch, Account No: 4091009473, Branch Code: 632005

MEDICAL AID

We can handle the claim on your behalf providing that:

  1. You are an active member of the medical aid
  2. You can provide us with a Medical Aid card and ID at least 24 hours before the appointment.
  3. There are funds available for Dentistry or Dental cover on your medical Aid.
  4. You agree to pay all patient portions within 7days after receiving a statement from us. If we do not receive your payment within 7 days, an admin fee of R50.00 will be charged with a further R15 penalty per month. Interest Charges are calculated at a rate of 1.5% every 30days (annual rate of 18%) based upon an unpaid balance outstanding 30days or more as of the billing date. Accounts that are not settled within 90 days, will be handed over for legal collection.
  5. You understand that we treat you according to the treatment you need and not according to medical scheme cover. You will be responsible for codes not covered by your medical aid.
  6. We do not handle claims for Orthodontic treatment.
  7. You are responsible to get pre-authorisation from your medical aid for all treatment that needs pre-authorisation.

Payment options are the same as above:

Terms and Conditions in terms of handing over an account.

  • The patient and/or guarantor consents that the practice may use a national Credit Bureau for tracing purposes if necessary.
  • Should the patient or guarantor fail to settle their account in full, the practice may proceed with listing the patient and/or guarantor at the Credit Bureau
  • In the event of legal proceedings for the recovery of an unpaid account, the patient and/or guarantor will be liable for the payment of legal fees at a rate between Attorney and own client. All parties named herein consent to the jurisdiction of the magistrate’s court should legal Proceedings be necessary for collection of outstanding amounts.

 I agree to the terms and conditions above

Payment Options

mediFin card

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