Three Rivers Patient Details Form

Three Rivers Patient Details Form
Person Responsible For Account

PrefixFull NamesSurnameID
Address

Street Address

Suburb

CityProvince

Postal Code
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.
Email
example@example.com

Patient Details

PrefixFull NamesSurnameID
Phone Number
Please enter a valid phone number.Format: (000) 000-0000.

Method of payment
Please take a clear photo of the patient's ID
Please take a clear photo of the front of your medical aid card
Please take a clear photo of the back of your medical aid card
Or upload your medical aid card

Cancelof

Ts & Cs:

Cash patients: eye test is immediately payable after testing. All goods are fully payable before ordering. If not making glasses / ordering contact lenses with us the full optometric examination will be charged (Code 11001/11081). An admin fee will be charged for all reports (Code 19001).

Medical aid patients: benefit confirmation is done as a courtesy & the member is still liable for all shortfalls not paid by the medical aid. All medical aid discounts will fall away if paying cash. A 50% deposit is needed on your co-payment before ordering & full payment before release of goods.

Own frame/own lenses/own script used: all at patient risk, the practice & lab does not take responsibility for breakages. We also do not take responsibility for glasses not made by our lab & scripts not provided by our practice.

Refunds & garuantees: No refunds on optometric examinations/services rendered, glasses already worn or products opened & used. Please ensure that you receive in good order before leaving the practice. Entry level lenses/budget frames - no garuantee, you are welcome to upgrade to a better product & pay the difference. Premium lenses/frames - 3 month garuantee. Premium coatings - 12 month garuantee.

Lay-buy of frames: will be resold & lenses kept on file if not collecting after 90 days, you are welcome to choose a new frame for requoting after 90 day collection.
I have read & agreed to the terms & conditions. I agree that above information is true & correct & that I am the member specified on the medical aid. I am aware that using someone else's medical aid is fraud. I agree that my information can be passed on to the medical aid for benefit checks & other medical professionals for referrals. I agree that I will be responsible for all additional costs incurred for handover of my account for collection.
Should be Empty: