THE WENTWORTH FOUNDATION
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Dental and oral Health Care Services Pledge
2021 - Annual Online Registration
*
Indicates required field
Name
*
First
Last
Work Address
*
Line 1
Line 2
City
State
Zip Code
Country
Area in which you work
*
Albert Falls
Amanzimtoti
Ballito
Berea
Bergville
Bluff
Blythedale Beach
Champagne Valley
Colenso
Dundee
Durban - Central
Durban North
Durban South
East Griqualand
Empangeni
Eshowe
Essenwood
Estcourt
Greytown
Hibberdene
Highmoor | Kamberg Valley
Hillcrest
Hilton
Himeville-Underberg
Hluhluwe
Howick
Ixopo
Jozini
Karkloof Nature Reserve
Kloof
Kokstad
Kosi Bay
Kwadukuza
Ladysmith
Margate
Matubatuba
Mkuze
Mooi River
Morningside
Mount Moreland
Mtunzini
Newcastle
Nongoma
Nottingham Road
Paulpietersburg
Pennington
Pietermaritzburg
Pinetown
Pongola
Port Edward
Richards Bay
Richmond And Byrne
Salt Rock
Scottburgh
Shaka's Rock
Sheffield Beach
Shelly Beach
Sodwana Bay
Southbroom
St Lucia
Umhlanga Rocks
Umkomaas - Aliwal Shoal
Umzimkhulu
Uvongo
Valley of a 1000 Hills
Vryheid
Wartburg
Weenan
Contact Telephone Number
*
Mobile
Email
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ID Number
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HPCSA Number
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Services you are willing to provide
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Scaling and Polishing
Fillings
Extractions
Root Canal
Crowns and Bridges
Implants
Other
If Other - Please specify in the description field below
Please advise the number of patients per service
*
Your reason for making this pledge
*
Terms and Conditions apply:
Registration to be renewed annually. Patients will belong to the Wentworth Foundation and the practitioner shall divest themselves from any personal financial gain. The practitioner shall not use any information provided to them for any purpose outside of the mission of the Wentworth Foundation.
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