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BESONDERHEDE VAN PASIëNT / PARTICULARS OF PATIENT
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* Required information.
Van / Surname: *
Voorname / Names: *
Noemnaam / Nickname: *
Geboortedatum / Date of birth: *
I.D. no: *
Huistaal / Home language: *
Woonadres / Residential address *
Pasiënt Tel / Pasiënt Tel: *
Tandarts / Dentist: *
Verwys deur / Referred by: *
Naam van Opvoedkundige Instituut / Name of Educational Institute:
Graad / Grade:
Sport aktiwiteite en stokperdjies / Sport activities and hobbies:
Geaardheid / Disposition:
Naasbestaande Naam / Next of kin Name: *
Verwantskap / Relation: *
Tel - Cell:
Work:
Home:

Address

321 Bulwer Street
Central CBD
Pietermaritzburg
3201

Appointments

E-mail: orthodontist@sainet.co.za
Telephone: 033 394 7635

Appointments can be made daily from Monday to Friday 08:00 to 16:30. You may also leave a message at any time for us to contact you on our answering service.

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