Kromboom Dental Centre charge medical aid rates. We however DO NOT deal directly with Medical Aids. Patients will need to settle their accounts first and claim back from their Medical Aid Provider.

Please note that this is a booking request form. One of our friendly receptionists will be in contact with you via your preferred method to solidify and confirm your booking(s).

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Patient Status

• Active Patient
• Inactive Patient
• New Patient

Name *

First

Last

Email *

Contact Number *

Cell Number *

Address *

PURPOSE OF DENTAL VISIT (you may select more than one choice) *

• Bleaching/Whitening
• Examination
• Re-evaluation
• Bonding
• Extraction
• Retainers(fixed or removable)
• Braces
• Fillings
• Root Canal Therapy
• Broken or missing teeth
• Implants
• Root planning & scaling
• Cleaning & check-up
• Oral Microbiology
• Deep Cleaning
• Cosmetic Dentistry
• Oral Surgery
• Sculpting(reshaping teeth)
• Crowns,caps & fixed bridges
• Pain
• Temporary filling or caps
• Dentures
• Periodontal therapy or surgery
• TMJ & bite plates
• Diagnosis of soft tissue lesions
• Porcelain laminates/veneers
• Wisdom teeth
• Emergency
• Post and core
• X-rays

PREFERRED DAYS AND TIMES OF APPOINTMENTS: *

Office hours: Monday to Friday 8:15 am – 7:00 pm and Saturday 8:00 am – 1:00 pm. Please provide several choices.

Preferred method to receive your appointment confirmation *

• Telephone
• Cell
• Email

Please note that this is a booking request form. One of our friendly receptionists will be in contact with you via your preferred method to solidify and confirm your booking(s). You are more than welcome to call into the practice on 021 696 9428 to speed up the booking process. We look forward to seeing you.

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