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Olympia Eye & Laser Centre 

General Information and Appointments:

If you would like to make an appointment to visit our Institute for a consultation, complete the form below

1. Routine appointment days are only on Monday, Tuesday and Thursday mornings.

2. Please give at least two weeks notice for an appointment.  You should be contacted within 2 working days of placing the request.  If you are not contacted please make a telephonic or fax request for appointment.

3. Always bring all your spectacles along.

4. If possible bring your contact lenses or details of your contact lenses along.

5. If you are interested in REFRACTIVE SURGERY [procedure to reduce or eliminate your spectacle wear], please obtain previous prescription details from your eye care physician or optometrist [as far back as possible]. You will need to discontinue wearing contact lenses for a period prior to the examination. Preferably do not place eye make-up on the day of the examination. Please be prepared to spend a few hours at the centre as various tests are usually performed.

6. Please, don't forget to bring your ID and medical aid card.

Patient Details

Surname:*
First name(s):*
Initial(s):
ID Number:*
Occupation:
Company/Business name:

Address and Tel/Fax Contact Details

Appointment Date:
   
How would you prefer to be contacted?
E-Mail Phone Fax
   
E-Mail Address*:
   
Cellphone Number:
Fax Number:
Home Telephone Number:
Work Telephone Number:
   
Postal Address:
Work Address:
Residential Address:

Above details are of the Main Member or of the Parents in the case of a dependant child.

Medical Aid Member Details

Main Member Surname:
Main Member First Name:
Main Member Initials:
Medical Aid Scheme:
Medical Aid Plan:
Medical Aid Number:

If You Have Been Referred To Us...

Name of referring doctor or optometrist:
Telephone number of referring doctor or optometrist:

If You Have Not Been Referred To Us...

Name of Doctor:
Number of Doctor:
Name of Optometrist:
Number of Optometrist:

Details of a friend or family member not living with you

Name:
Telphone Number:

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