With our platform filling in Optipharm Chronic Form only takes a couple of minutes. Main Member and Medical Scheme details Surname First name s ID Number Gender M F Medical Scheme Membership number Scheme Option Telephone H W Cell Email B.įeel all the key benefits of submitting and completing forms on the internet. To avoid administrative delays please ensure this application is completed in full* A. Application form for enrolling for chronic medicine delivery How to complete this form Please complete with black ink use one number per block and print clearly. Optipharm reserves the right to hand over any member/patient to its collection agent for the recovery of monies due in lieu of services rendered* The applicant acknowledges that providing correct and authenticated delivery address details remains the APPLICANT SIGNATURE DATE. The applicant acknowledges that he/she is ultimately responsible for payment of services to the provider and as such undertakes to pay Optipharm any monies and to inform Optipharm of any changes pertaining to their Medical Scheme. Optipharm is unable to accept medicine returns as governed by the Pharmacy Council and the Code of Conduct for Good Pharmacy Practice. Responsibility address if notified on time. ![]() Preferred delivery address Home Work Doctor s rooms Postal Address Unit/ Building No Street Address Town Province Postal Code Please send the completed form and your current valid prescription back to us via Fax 0 OR Email enrolments optipharm*co. About the patient Dependent number Telephone if different from the main member C. Main Member and Medical Scheme details Surname First name s ID Number Gender M F Medical Scheme Membership number Scheme Option Telephone H W Cell Email B. Preferred delivery address Home Work Doctor s rooms Postal Address Unit/ Building No Street Address Town Province Postal Code Please send the completed form and your current valid prescription back to us via Fax 0 OR Email enrolments. To avoid administrative delays please ensure this application is completed in full. ![]() ![]() Optipharm will notify you when a new prescription is required but it remains your responsibility to provide a valid prescription s to ensure that there is no interruption in your medicine delivery service. DISCLAIMER Prescription supplied without a current valid prescription. Authorization of chronic medication by your Medical Scheme remains your responsibility Optipharm will be unable to dispense your medication unless it is correctly authorized. Za Post PO Box 4975 Rivonia 2128 Please attach your prescription to this application without a valid script we cannot dispense your medication.
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