Patient Information

To speed up the administration process when you arrive at the practice, please complete and submit this form.

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PLEASE TELL US ABOUT YOURSELF

Surname *

First Name *

Title *

D.O.B *

Address *

Code *

I.D Number*

Home Tel *

Cell Phone *

WhatsApp No (if different)

Email *

Are you on Facebook?

Are you on Instagram?

Handle?

Please follow us on Instagram Zena_Jacobson_Optometrist

PLEASE TELL US WHERE YOU WORK

Business Name

Address

Occupation

Email (If different from above)

Work Tel

PERSON RESPONSIBLE FOR THE ACCOUNT IF DIFFERENT FROM THE ABOVE

Surname

First Name

Title

I.D Number

Relationship to Patient

Occupation

Home Tel

Cell Phone

Business Name

Address

Email Address

Work Tel

PLEASE GIVE US YOUR MEDICAL AID DETAILS

Medical Aid Name *

Number *

Plan *

Dependant Code *

Preferred method of communication SMSEmailTelephoneWhatsApp

How did you hear about us?

Please let us know who referred you so that we can thank them

PLEASE NOTE:
Whilst every effort will be made to claim payment from your medical aid on your behalf, please note that you remain responsible for any outstanding balances not covered by your medical aid.

Signed consent in terms of the POPI Act

We periodically send out newsletters, reminders for your next examination and other relevant information using email, SMS and WhatsApp that could benefit you. As this communication can be classified as Direct Marketing in terms of the POPI Act, we would appreciate your consent that you would like to receive these communications and that we can retain your details on our communications database. All communications have an unsubscribe button for you to opt-out at any time.

I hereby GIVE CONSENT to Zena Jacobson Optometrist to utilise my SMS, WhatsApp, email or other communication facility in order to inform me when I am due for my next examination; that my spectacles or contact lenses are ready for collection, and from time to time inform you about special promotions. The contact data may include my name, email address, telephone number, postal address and/or social media account identifiers.

I hereby GIVE CONSENT to Zena Jacobson Optometrist to use my image and for it to be posted on its social media site.

I hereby DO NOT GIVE CONSENT to Zena Jacobson Optometrist to utilise my SMS, WhatsApp, email, or other communication facility in order to inform me when I am due for my next examination, that my spectacles or contact lenses are ready for collection and from time to time about special promotions. The contact data may include my name, email address, telephone number, postal address and/or social media account identifiers.

I hereby DO NOT GIVE CONSENT to Zena Jacobson Optometrist to use my image to be posted on our social media site.

I give Zena Jacobson Optometrists consent to do a comprehensive eye examination on me as stated above, to determine the health of my eyes and obtain a prescription for a spectacle or contact lens correction.

If I have a medical aid benefit, I give my consent to send the details of my prescription, as well as the results of the examination (ICD10 Codes) to my medical aid, in order to claim payment of the consultation, spectacles and / or contact lenses on my behalf.

In the event of a referral to another healthcare practitioner, I give consent to disclose the results of my examination for the benefit of the referred practitioner’s treatment programme.

I give consent to Zena Jacobson Optometrist to share my personal details and my prescription with the practice’s suppliers and laboratories to order the required spectacles or contact lenses prescription finalised during the eye examination, to correct my vision following the consultation.

I give consent to allow the Zena Jacobson Optometrist to send my personal information to the medical aid or another organisation for processing the claim, which will include my name, address, medical aid number, prescription, and any other data required to process the claim for payment.

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