Patient information sheet

Please fill in this form before your visit. It takes about 5 minutes. Fields marked "required" must be filled in.

Patient details

Title required

Choose a title.

Name and surname required

Enter the patient's name and surname.

Date of birth required

Enter the patient's date of birth.

ID number required

South African ID number, or passport number.

Enter the patient's ID or passport number.

Cellphone number required

Enter a cellphone number with at least 10 digits.

Work number

Enter an email address in the format name@example.com, or leave it empty.

Occupation

Language

For example English or Afrikaans.

Medical aid details

Leave these empty if you do not have a medical aid.

Scheme

Plan

Membership number

Person responsible for the account

The patient is the person responsible for the account

Title required

Choose a title.

Name and surname required

Enter the name and surname of the person responsible for the account.

Date of birth required

Enter this person's date of birth.

ID number required

Enter this person's ID or passport number.

Cellphone number required

Enter a cellphone number with at least 10 digits.

Work number

Enter an email address in the format name@example.com, or leave it empty.

Occupation

Home number

Employer

Physical address required

Enter the physical address.

Postal code

Postal address

Leave empty if it is the same as the physical address.

Postal code

Work address

Postal code

Nearest relative or friend

Name and surname required

Enter the name of a relative or friend we can contact.

Contact number required

Enter a contact number with at least 10 digits.

Medical aid payments

For your convenience we will (if so required) submit your account to your medical aid for direct payment.
Medical aids may only contribute a portion of your account and not necessarily pay the full amount.
Although every effort is made to confirm the correct amount contributed by your medical aid, it is merely an estimate and can therefore change.
Any amount not paid by your medical aid is payable by you.
I agree that I am liable for all attorney and own client fees, collection charges and interest should I fail to settle any amounts due in terms of this agreement.
We reserve the unequivocal right to have the person responsible for the account listed on TransUnion ITC and take such steps as deemed necessary.

Consent to the fees being charged by this practice

I, the undersigned, do hereby:

Acknowledge that I have been informed that this practice does not charge the rates that the Department of Health has unilaterally determined for optometrists and which are known as a Reference Price List (RPL);
Confirm that I am aware that this practice fees are charged up to 3 times the RPL;
Confirm that I am aware that the RPL values for services are available from the Department of Health (Tel. No: 012 312 000) and the Health Professions Council of South Africa (Tel. No: 012 338 9300) and www.doh.gov.za.

Agreement and signature

Full name of the person signing required

Enter the full name of the person signing.

I, the undersigned, agree to the conditions above and have read and understood the terms of the content thereof. required

Tick this box to agree to the conditions.

Signature (handtekening) required

Date (datum):

We use this information only to look after you as a patient and to manage your account. Read our privacy policy.