Lorem ipsum dolor amet, consectetuer adipiscing elit. Aenean commodo ligula eget dolor massa. Cum sociis natoque penatibus et magnis dis parturient montes, nascetur ridiculus mus.


Follow Us:

Patient online form


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)

Please Accept our terms*

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.

× How can we help you?