Patient Information Form

please fill in the following form so that we have your information for your consultation. all information is kept confidential. please contact us if you have any queries ( / 0448734695 / whatsapp 0662923123)

Please reload the form once you have completed & submitted it if you would like to complete it for a second person.

(Please send us a copy of your card to WhatsApp 0662923123 or
* You can select more than one option
* You can select more than one option
Please list the device and the working distance of each. This distance is VERY IMPORTANT when calculating your prescription for the reading, iPad, laptop or computer.
* Please note that if your blood pressure or sugar levels are too high it will affect your eye's prescription possibly causing it to be incorrect. Please reschedule your appointment if either is unstable.
* Follow us & tag us with your new glasses @ritawallsoptom
* 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.