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NEW PATIENTS – PLEASE COMPLETE

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




A) Patient Information: (Please provide us with an original driver’s license or ID)




B) Person responsible for account (if not the same as patient)




C) Medical Scheme Information: (Please provide medical aid card)

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Optical Benefit Confirmation

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.




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