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Practice Number: 0211389



By signing this form, you acknowledge that you have understood and agreed to the following:


  1. That you have received and read the Consent to Disclosure of information.

  2. That you take full responsibility to pay any monies owing to Dorfling-Smith Optometrists.

  3. To always ask, even after you have left the practice, if you were uncertain about something. You can ask practice staff of the Optometrist. If you keep quiet, practice staff and the optometrist will assume that you have understood everything and was in agreement with any processes, consent, policies or forms.

  4. If you do not keep your appointment (for any reason whatsoever, apart from emergencies) and you have not let us know at least 24 hours before the appointment, we reserve the right to change a cancellation fee, as we have kept the slot open for you and could not assist another patient.

  5. I hereby give consent to electronic communication.


  1. The Practice processes (collects, uses, stored, or otherwise deals with) your personal and special personal information (“personal information”) in accordance with section 32 of the Protection of Personal Information act. 2013 (“POPIA”) in order to provide you with the prescribed treatment and the required administration in relation to such treatment.

  2. The personal information we collect may include, but is not limited to, the information requested in this form, as well as any health information collected or provided during your consultations and /or treatment.

  3. It is mandatory for you to provide the requested personal information in order for the Practice to provide you with appropriate treatment, including follow up treatment and to properly administer our accounts to you. It is your responsibility to provide true and complete personal information ant to update the information we hold should your personal details change. Your failure to provide this information may impact the treatment provided to you and may hinder the appropriate administration of your treatment and our accounting to you.

  4. We will keep your information confidential, subject to the provisions set out in the Consent to Disclosure of Information document.

  5. We will take reasonable and appropriate measures to secure your personal information, but is impossible to guard against all unlawful and unauthorised access of personal information (for example through unlawful email breaches). We do not take any responsibility for any harm caused using your information by unauthorised parties.

  6. Any privacy related enquiries, requests for access to information or complaints can be made by emailing the Practice on


Lizelle Dorfling-Smith

B.Optom (RAU) CAS (USA)

Practicing from Prof. J.T Ferreira Optometrist’s rooms

T: 011 67502638 C: 082 8240 682 E:

Savannah Office Park, Aloe Building, Rugby St., Weltevredenpark, Roodepoort, 1709

Thank you for signing our Privacy Notice Consent Form. You may close this window & proceed to BOOKING

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