Patient Registration Form

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Acknowledgement of Debt

(To be completed once only)

As Alps Dental Centre, we will do everything possible to recover claims submitted to your medical aid for the services we have provided you. However, in some cases, medical aid may be unable to honor these claims despite our best efforts to collect the amounts due.
Please complete the following acknowledgment after reading:

I agree to settle in full all amounts owed to Alps Dental Centre for the services and/or procedures performed on me if any of the following occurs:

i.The medical aid refuses to honor the claims.
ii.Shortfalls arise due to the non-approval of procedures.
iii.The medical aid exceeds sixty (60) days without payment.
iv.Medical aid fails to honor the claims for any other reason.

By signing below, I acknowledge my responsibility for payment under the conditions outlined above.

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