Online Appointment Form

Date of Birth:

Have you been tested Rita Frank Optometrists before?YesNo

Appointment Date:

Do you currently wear contact Lenses?YesNo

Hard or Soft lenses?Hard LensesSoft Lenses

Have you been referred by a doctor/therapist?YesNo

Medical Aid NameNHPNammedPsemas (please remember your 5% contribution for the eyetest)ProsperityBankmedNapotelNamdebInvestmedHeritage HealthOther