Appointment Form - Dr Wilson Dental Care

Appointment

Name *

First

Last

Email *

Phone Number *

Gender *

Male
Female

Patient Status – Are you a new Patient? *

Date and Time: *

Kindly note that the doctor is available in the Corlett drive, Illovo, Sandton branch in the mornings between 9AM-12PM and at the Braamfontein branch in the afternoons between 1PM-5PM. (our admin team will alert you on the available time slots).

Payment Terms: *

Medical Aid
Cash

Medical Aid name: *

When last did you have a dental check-up and clean?

Dr Wilson Dental Care is committed to protecting and respecting your privacy, and we’ll only use your personal information to administer your account and to provide the products and services you requested from us. From time to time, we would like to contact you about our products and services, as well as other content that may be of interest to you. If you consent to us contacting you for this purpose, please tick below to say how you would like us to contact you: *

I agree to receive other communications from Dr Wilson Dental Care and partners.

Reason for appointment: