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Patient Forms
Patient Forms

Patient Information Form

To speed up the administration process when you arrive at the practice, please complete and submit this form.
Note: The information fields in the Patient Details section must be filled in.

Patient Details

Medical Aid Details

Person Responsible for Your Account

NEAREST FAMILY OR FRIEND

Yes

Terms and Conditions:

Submission and signature on a quotation is contractually binding. Orders can not be canceled after the quotation has been approved.
According to the National Credit Act, we can not provide credit as we are not a registered credit provider. As a result, all due fees are payable before receipt of goods.
Glasses and contact lenses can not be ordered before receiving 50% of the amount due.
We reserve the indisputable right to place the person responsible for the TransUnion ITC account in case of default, and to take further recovery steps.
MEDICAL FUND PAYMENTS: For your convenience, we will (if you require) submit your account to your contracted fund for direct payment to us.
Medical Fund only contributes a portion of the account and not necessarily the full amount.
Although all possible attempts are made to determine the correct contribution through your fund, it is still only an estimated value and is not guaranteed. When calculating your personal contribution to the account, we use this estimated amount that may change.
Any amount not paid by your fund remains your responsibility.
BY SUBMITTING THIS FORM YOU AGREE THAT YOU HAVE READ THE ABOVE & ACCEPTED THE CONDITIONS

Our Brands

Business Hours:

Mon - Fri: 9:30 - 16:30
Sat - Sun: 10:00 - 16:00

Shop No. 10, BluBird Centre, Cnr Atholl Oakland & Fort Str, Birnam, Johannesburg

Business Hours

Mon-Fri: 10:00 - 16:00
Sat - Sun: 10:00 - 16:00

Shop No. 10, BluBird Centre, Cnr Atholl Oakland & Fort Str, Birnam, Johannesburg
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