Patient Information Form

To speed up the administration process when you arrive at the practice, please complete and submit this form.

Please Note: The information fields in the Patient Details section must be filled in.


1. All of the above information is complete and correct.
2. In the event that my medical aid (if any) fails to pay any amount due, punctually, in full or at all, I will pay such amount forthwith upon demand. Confirmation of medical aid benefits is not a guarantee of payment.
3. The amount due in terms of this agreement will be payable as follows, 50% non refundable deposit on order and balance upon collection.
4. Repairs, adjustments and transfers – although we take the utmost care with our patient’s spectacle frames and lenses, they are handled at your own risk.
5. Interest shall be charged at a rate of 1.5% per month, from the date of the first statement of account to the date of payment.
6. Should it become necessary to institute legal proceedings against me for recovery of any amount due I agree to pay all costs on the scale as between attorney and own client including tracing fees and collection commission.
7. Collection must be effected within seven (7) days of written notice addressed to the patient’s (client’s) domicilium citandi et executandi* failing which the goods deemed to have been collected and the full amount being due, owing and payable, despite the non-collection.
8. The patient’s (client’s) chosen domicilium citandi et executandi* shall be the address as reflected and specified in the space provided above.
9. Discounts and promotions are subject to change without notice and while stocks last. Errors and omissions expected.