Private px responsible for own account A
Private px who is a dependant A+B
Px who is main member of MedAid A+C
Px who is a dependant on a MedAid A+B+C
Your Name and Surname*
Upload original diver's license or ID*
Your Name and Surname
Relationship to Patient*
Full Name of Main Member (If not the same as in B)
ID number (If not the same as in B)
Medical Aid Name
Please Accept our terms*
For spectacles, a 50% deposit and the signed invoice is required for authorisation to go ahead with the optical lenses as stated in the" "original quotation. The person signing the invoice confirms that they have received authorisation from the person " " responsible for the" "account to do so, and is thereby authorising on behalf of that responsible person, that Spectacle World may proceed with the ordering of the optical goods. The balance of the order is to be paid on collection. When purchasing contact lenses, the invoiced amount should be settled upfront. Thank you for providing us with your updated information and for your consent to communicate with you regarding your account and optical requirements/products.
Optical Benefit confirmation: Please complete your current available optical benefits as confirmed with your medical aid and supply a reference number in the block below. The medical aid confirmation slip below can be used as a guide to confirm your available specified optical benefits. As a service we will assist and follow up with your reference number. Please remember that confirmed benefits are not a guarantee of payment to the practice.
To confirm your current available Optical Benefits on your Medical Aid plan, Please complete form below.
Px Name & Surname
Medical Aid + No
Medical Aid Option
Tints / Surfaced Lenses / ARC / Hard Coat / Photochromic Lenses
M/Aid Consultant/Ref no
Medical aid plan date