Terms & Conditions

By signing below, I certify I have read and understand the foregoing, have had the opportunity to ask questions and have them
answered and accept the above conditions, terms and acknowledge that Dental Co don`t charge medical aid tariffs - I agree to pay all
charges for which I may be legally responsible including, medical aid, co-payments, and non-covered Codes. I also agree in the event
my account must be placed with an attorney or collection agency to obtain payment, I will pay the reasonable attorneys' fees and other
collection costs incurred by Dental Co . I understand and agree this document will remain in effect for all future visits to Dental Co ,
unless specifically rescinded in writing by me.

We need the above information so that we can help obtain the dental benefits you are eligible for. This may require submitting the
Doctor’s treatment plan to the medical aid for a pre-determination of benefits, or authorization by phone and internet of which a fee of
R250 will be charged - Dental Co can NEVER guarantee payment by your Medical Aid. The Medical Aid’s contract is with you and your
employer, and is the members responsibility to obtain reasons for none payment.

I understand and agree that, regardless of my Medical Aid Benefits, I am ultimately responsible for the balance on my account for any
services rendered. I certify the information on the Patient Information Form is true and correct to the best of my knowledge. I will
notify Dental Co of any changes in my health status or any changes in the above information.

I also take note of the Administration fee that will be charged for each /claim that will be submitted to my medical aid.