By Design | Dr Nikita Morar (2026 form)Dr Nikita MorarDENTAL PRACTITIONER (Practice No: 0832219)Shop 18 | Riverside Shopping Centre | 319 Bryanston Drive | BryanstonSECTION FORM OF ADMISSION / TOELATINGSVORM Responsible person for payment of practice account /Verantwoordelike persoon vir betaling van praktykrekeningPersonal Details Title / Titel Dr Mr/Mnr. Mrs/Mev. Miss/Mej. NonbinaryFirst NameLast NameCitizenshipAre you a South African citizen? / Is u 'n Suid Afrikaanse burger? Yes NoSouth African DetailsID NoForeign National DetailsIf you entered a passport number, please specify your country of origin. e.g. (A2074275 / 1975/09/12)Contact & Address DetailsResidential Address / WoonadresPostal Address / PosadresCell No / Sel-NoE-mail address / E-pos adresEmployer InformationName of Employer / Naam van werkgewerTel No / Tel-NoLanguage Preference / TaalkeuseLanguage Choice / Taalkeuse English AfrikaansAccount ResponsibilityIs the information of the person responsible for the settling of the account the same as the information of the patient? Yes NoPatient and individual responsible for the account's information is the same / Pasiënt en persoon veantwoordelin vir die rekening se inligting is dieselfde Yes NoTitle / Titel Dr Mr/Mnr. Mrs/Mev. Miss/Mej. NonbinaryFirst NameLast NameID NoResidential Address / WoonadresPostal Address / PosadresCell No / Sel-NoE-mail address / E-pos adresMedical Aid DetailsDo you have Medical Aid? Yes No Medical Aid Information We are not a medical aid contracted practice and cannot claim from your medical aid on your behalf. This information will appear on statements that will allow you to claim back from your medical aid. Do you understand and acknowledge that we are not a medical aid contracted practice? Yes NoName of Medical AidMedical Aid plan/scheme. Eg; Profmed Acute PlusMedical Aid numberDependent CodeMedical History / Vorige Mediese GeskiedenisHeart Diseases / Hart Siektes Yes NoPlease specify the heart disease.Diabetes / Suikersiete Yes NoHypertension / Hoë Bloeddruk Yes NoEpilepsy / Epilepsie Yes NoStomach Diseases / Maag Yes NoLiver Diseases/ Lewer Yes NoKidney Diseases / Nier Yes NoEar-Nose-Throat / Oor-Neus-Keel Yes NoJoint Diseases / Gewrigte Yes NoSkin Diseases / Vel siektes Yes NoAllergies / Allergie Yes NoPlease indicate what you are allergic too. / Dui aan waarvoor u allergies is. Please list medical conditions not indicated above. / Toon asseblief mediese kondisies wat nie genoem is nie aan.Medication / MedikasiePlease give list of medication (If no medication is used, please indicate that no are used.)/ Gee lys van medikasie (As geen medikasie gebruik word nie, dui aan dat geen gebruik word nie.)REFERRING DOCTOR / VERWYSENDE DOKTERWere you referred? / Was `n verwys? Yes NoName of Doctor / Naam van DokterTel No / Tel - NoAddress / AdresCLOSEST FAMILY MEMBER OR FRIEND / NAASTE FAMILIELID OF VRIENDTitle / Titel Dr Mr/Mnr. Mrs/Mev. Miss/Mej. NonbinaryFirst NameLast NameTel No / Tel - NoTerms and Conditions / Terme en Voorwaardeshttps://dentistrybydesign.co.za/wp-content/uploads/2026/04/By-Design-Dental-Practice-Informed-Consent-2023-1.pdfI accept the terms and conditions. / Ek aanvaar die terme en voorwaardes. Yes NoSubmit Form
