By Design Dental Practice
Terms and Conditions
I, the undersigned, irrevocably declare and undertake the following:
Dental records
1. That I consent to the taking of photographs and/or x-rays which will be used by the practice as patient records for
treatment planning.
2. Photographs might be used for teaching, website, social media sites and informative purposes. Undersigned will be
anonymous in all posted photographs. Mark X to which photographs you DO NOT give consent:
Payment and Treatment Costs
1. That I have been fully informed that By Design Dental Practice is a private practice and does not charge any Medical
Aid-based rates. Patients are fully responsible to settle the account on the day of treatment.
2. Treatments exceeding 90 minutes will require a 50% deposit prior to confirmation of the appointment.
3. I am aware that By Design Dental Practice fees are more than most Medical Aid rates and benefits.
4. I acknowledge that it is my obligation to request a written cost estimate/treatment plan before the commencement of
my or any dental treatment. Additionally, I have the right to discuss the treatment plan before the commencement of
dental treatment.
5. I understand that no treatment estimation will be given without X-rays and digital photos being taken of the patient.
6. I acknowledge that I have to consult with my medical insurer/provider on their portion of the payment of the cost
estimate. The By Design team does not submit claims directly to medical aid providers. I understand that the patient is
liable to settle the treatment costs.
7. I acknowledge that treatment costs must be settled in full before a detailed invoice will be provided to me to submit to
the medical aid insurer. An invoice cannot be provided prior to the consultation or treatment.
8. That I accept full responsibility for my account to be settled directly after each visit.
9. If the account is not settled and this account is handed over for collection, I consent to legal fees on an attorney and
client scale, collection commission, tracing fees and VAT (If applicable). The interest of 2% per month will also be payable
to the By Design Dental Practice. Sixty-day accounts will be handed over for collection.
10. That an additional after-hour fee of R 1 500 will be charged outside normal working hours. Working hours are between
09:00 and 18:00 on weekdays.
11. That I accept one of the following payment methods: Credit Card, Debit Card, Cash, or EFT (to be made in-office).
Appointment Cancellation
1. I acknowledge that I have the right to cancel my dental appointment. Appointments should be cancelled 24 hours in
advance.
2. If I cannot attend an appointment due to an emergency, it remains my responsibility to inform the By Design Patient
Relations Manager via email, WhatsApp message or phone call.
3. I accept that a fee of R 1 500 per hour, or a portion thereof, will be charged for all appointments not kept and not
cancelled 8 hours prior to the appointment.
Communication
1. I have the right to contact the By Design practice manager immediately if any dispute or complaint arises. Please note
that communicating directly with the medical healthcare provider via social media, including WhatsApp is discouraged.
Official communication should occur via the official By Design communication channels.
2. In the event of a contractual dispute or any cause of action, ligation shall only be instituted in a court of the Republic of
South Africa.
3. That I selected the address below as my domicilium citandi et executandi (nominated residential address) for all
purposes under the agreement.
4. That any registered notice which is forwarded to this address will be deemed to have been received five days after the
date of posting.
5. I undertake to inform the By Design Dental Practice, in writing, one week in advance should this address change.
6. I give consent that By Design team practice may contact me via SMS, WhatsApp or e-mail regarding the confirmation of
my appointments, and recalls and inform me of practice news.
Minors & Parents
1. As the parent/legal guardian of a minor patient, I acknowledge that I am responsible to accompany my child to
treatments and treatment plan discussions.
2. As the parent/legal guardian of a minor patient acknowledge that they are responsible to settle payments of treatment
in person.
Disclosure of Medical Conditions and Medication
1. I will disclose any medical condition, medication or medical treatment which could influence the success of dental
procedures or treatments. If there are any changes to the disclosed medical conditions, treatments, or medication, I
will inform the By Design team before treatment or dental procedure.
POPI Regulations
All parties agree that they will comply with POPI regulations and process all the information and/or personal data in respect of
the services being rendered in accordance with the said regulation and only for the purpose of providing the services set out in
the agreement to provide services.
The By Design Dental Practice (also service provider), all the parties to this agreement, the service provider’s employees and the
client’s employees and any subsequent party/parties to this agreement acknowledge and confirm that:
1. One or more of the parties to this agreement will possess and will continue to possess information that may be classified
or maybe deemed as private, confidential or personal information.
2. Such information may be deemed as private, confidential or personal information in so far as it relates to any party to
this agreement.
3. Further, it is acknowledged and agreed by all parties to this agreement that such private, confidential or personal
information may have value and such information may or may not be in the public domain
