Patient Onboarding | Sunny Road Optometrist

Welcome to Sunny Road Optometrist — patient onboarding 👋 Please complete this quick form before your visit — it captures your details and medical aid (with a photo of your card) so check-in is fast and we're fully prepared for you. It only takes a few minutes.

Patient

Title

First name *

Surname *

Preferred name

Date of birth *

Cell *

10 digits starting with 0 — e.g. 0820000000 (no spaces)

Address

Street address

Suburb

City / town

Postal code

Medical aid

Medical aid scheme

Type a few letters and pick yours from the list.

Plan / option

Membership number

Main member full name

Main member ID number

13 digits (optional)

Main member date of birth

Relationship to main member

Photo of your medical-aid card

📷 Card front 📷 Card back

School & visit

School

Grade

Referring therapist / OT / teacher

Reason for visit / main concern

POPI consent — terms & conditions of processing personal information

1. Definitions

'Dependant' means the spouse or partner, dependent children or other patients of the patient's immediate family in respect of whom the patient is liable for family care and support; or any other person who, under the rules of a medical scheme, is recognised as a dependant of a patient. 'Optometrist' means Ariella Meyerowitz. 'Patient' means the user of healthcare services and/or their guardian. 'Personal Information' means information that identifies or relates specifically to the patient, including all health and medical information, personal identification and benefit information as defined in POPI. 'POPI' means the Protection of Personal Information Act, 4 of 2013.

2. Consent for processing

The patient consent applies to the sharing of personal information with: the patient's medical scheme; where the patient is a minor, the patient's parents and/or guardians; pathologists, ophthalmologists and other medical practices; other optometrists; and authorised staff members or service providers.

3. Maintenance of consent

If there are any changes to these terms and conditions, the Optometrist will advise the patient within 30 days. It is the patient's responsibility to review them so changes are acknowledged. The patient confirms all information provided is true and correct, including for dependents who cannot provide independent consent, and undertakes to communicate any changes to the Optometrist so systems can be updated.

4. Consent & compliance in terms of POPI

The patient's consent is provided with acknowledgement and acceptance of the following. Purpose: the patient's medical scheme provider; the patient's parents/guardians (where a minor); pathologists, ophthalmologists and other medical practices; other optometrists; and authorised staff members or service providers. The consent will be used to: share the patient's personal information electronically with the chosen medical aid provider, the Optometrist's partners and service providers; store it in a secure backup/cloud storage facility or secure filing system; process it for maintaining the patient's medical scheme services and providing additional services including ICD-10 codes; use it for medical research, to optimise and facilitate treatment (including emergencies); use it for invoicing, payment and refunds; and retain it within statutory limits.

Intended recipients are the patient, the patient's medical aid providers, specialists and pathologists (including practice staff), the Optometrist, its administrator, clinical service providers, medical care facilities and affiliates, and — where appropriate — emergency medical services. Personal information is only provided upon the patient's consent.

Right to withdraw consent. Consent for accessing, using, transferring, sharing, storing and collecting the personal information of the patient or their dependents can be revoked at any time by contacting the Optometrist and completing the required documentation. If all consent is revoked, information is retained as required within statutory limits and thereafter irrevocably deleted/destroyed.

Storage & retention. Personal information is stored in a cloud-based/backup server and/or secure hard-copy filing meeting POPI and international data-protection requirements, and retained for as long as the patient is treated, then deleted within statutory limits.

Patient consent

The patient hereby consents to the use and processing of his/her or his/her dependent's personal information as set out in this agreement, and gives permission for the Optometrist to give the patient's (or dependent's) personal information, including diagnosis and other relevant clinical information required for treatment, to his/her medical aid provider. The patient confirms he/she has had an opportunity to read and comprehend these terms, has had questions answered, gives consent of his/her own free will, and has permission of his/her dependent(s) to give their consent.

Cancellation policy

I understand that if I do not cancel my appointment at least 26 hours before the scheduled appointment time, I may be charged a cancellation fee.

Please sign below *

Cancellation policy: if you do not cancel your appointment at least 26 hours before the scheduled time, a cancellation fee may be charged.

I accept the POPI Act and consent to Sunny Road Optometrist processing my (and my dependants') personal information as set out in the terms above. I understand I am financially responsible for any amount not covered by my medical aid, and I accept the 26-hour cancellation policy. I confirm the details I have provided are correct and complete.

Thank you!