Age Date of Birth / ID number * Cellphone Number Work telephone Number Home telephone Number Email Residential Address * Postal Address * How would you prefer to be contacted? Occupation Employer Chronic Medical Conditions Are you on a Medical Aid? Medical Aid / PLAN Medical Aid / MAIN MEMBER Medical Aid / MAIN MEMBER ID NUMBER Medical Aid / MEMBERSHIP NUMBER Medical Aid / PATIENT DEPENDENT NUMBER TERMS & CONDITIONS *
* A 50% NON-REFUNDABLE DEPOSIT of the patient’s portion is payable before spectacles are ordered & the settlement is payable on collection. When you sign a quote or pay a deposit, you are confirming that you are happy with the tested prescription and give us permission to proceed with making the glasses.
* We confirm your medical aid optical benefits on your behalf, but the benefits given to us by the medical aid are NOT A GUARANTEE OF PAYMENT. All unpaid amounts are the responsibility of the patient. All claims are submitted to your medical aid on the day of treatment / when the glasses are ordered.
* Please note: your vision is affected by HYPERTENSION and DIABETES. Please ensure your blood pressure and sugar levels are stable on the day of the eye test, and that you make us aware of your condition.
* Please note that when using your own frame, LENS FITTING IS DONE AT YOUR OWN RISK. We will not be held liable for breakages when fitting lenses. When using another Optometrist’s prescription we are not held liable if you can’t see clearly with it.
Please take note of the following:
- Most medical aids do not pay Medical bills in full, depending on the option. There is likely to be a difference in what you are billed and what your medical aid ultimately pays. Should there be a difference between the two, it will be your responsibility to settle the shortfall. Although the practice submits your claim to the medical aid on your behalf, it remains your responsibility to follow on any unpaid claims and to lease with your medical aid on any queries that may arise. Patients accept personal responsibility for the payment of their account.
- Accounts are emailed or posted as requested in good faith - we cannot accept responsibility for failings of postal services or emails. If you do not receive an account, it remains your responsibility to request for a copy of the account or to follow up on any outstanding balance.
- Please note if payment is not made within 90 day, the account will be handed over to our debt collectors for collection.
- The Patient and/or guarantor consents that the practice may use a national credit bureau database for tracking purposes if necessary. Should that patient and/or guarantor fail to settle their account in full, the practice may record the patient and or guarantor’s default with a Credit Bureau, which will affect your credit rating. In the event of legal proceedings for the recovery of an unpaid account, the patient and/or guarantor will be liable for the payment of legal fees at a rate between the Attorney and own client.
- All parties named herein consent to the jurisdiction of the magistrate’s court should legal Proceedings be necessary for collection of outstanding amounts. Where is your vision blurry? How many hours a day do you work on a computer? When was your last eye test? What glasses are you currently wearing? (You can choose more than one option) Have you had any eye operations? Do you have a family history of eye conditions (e.g. Glaucoma)? Are you experiencing any other symptoms / problems? Would you like to receive quarterly emails with our specials? Where did you hear about us?