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OptiCHEQ Registration
Registration
BHF Practice No:
Practice Name:
Address details
Postal address:
PO Box:
City:
Code:
Physical address:
Street:
Suburb:
City:
Code:
Contact details
Business Telephone:
Fax:
Cellphone:
E-mail address:
Demographics
Responsible Optometrist:
Designation
:
Owner
Manager
Additional qualification:
CAS
OD
Physical situation:
City
Rural
House
Mobile
Major Shopping Centre
Office Park
Suburban Shopping Centre
Equipment
Digital recording device
Field Screener
Field Plotter
Corneal Topographer
Keratometer
Tonometer
Bank details
Bank:
Branch code:
Account number:
Type of account:
-------- (select one) --------
Cheque/Current
Credit Card
Savings
Authorisation to debit:
-------- (select one) --------
Yes
No
Software
Operating System:
-------- (select one) --------
Windows 98
Windows 2000
Windows XP
MS Dos
Other
Optometry Software:
-------- (select one) --------
Optimax
Vision2000
Health Focus
Spec Pac
Stage-7
Pro Opt
Other
Membership
SAOA:
(select one)
Yes
No
SAOA Membership No:
PPN:
(select one)
Yes
No
PPN Membership No:
Chaisma:
(select one)
Yes
No
Chaisma Membership No:
Other:
(select one)
Yes
No
Specify:
Membership No:
Franchise
Stanley & de Kock
DVN
Spec Savers
Spectacle Warehouse
Spectacle Centre
Eagle Vision
Torga
Other
None
