First 5 who post a valid entry will win! Running between Aug 8-14
Patient Information
This is required.
Date of Birth
This is required.
This is required.
This is required.
This is required.
Medical Aid Details
Medical Aid Details
Main Member Details
How Did you Hear About Us
Google
Social Media
Friend/Family
Shopping Centre Advertising
Other
This is required.
If other please specify
I the undersigned take full responsibility in case of the Medical Aid not paying the account in thirty ( 30) days.
This is required.
I take full responsibility for all collection costs on tracing fees.
This is required.
I understand that my account is my own responsibility and that I will need to follow up payment myself with my Medical Aid if not paid in due time.
I give permission to La Boutique Eyewear to send my prescription details to a Specialist , in the case of a referral.
This is required.
I confirm details above are correct and true to my knowledge.
This is required.
Submit
powered by:
Surge
.
Media
