Clinic – dB Custom

Name *

BD Number *

Date of Birth yy/mm/dd *

Phone *

Work Place *

Shaft *

Contractor/Permant employee *

Upload RX SLIP (OR) Optometrist Prescription *

Click or drag a file to this area to upload.

This upload is compulsory. It will upload a RX slip or an optometrist prescription. Wait for upload to complete, then press the submit button.

Upload Optometrist Prescription (OPTIONAL)

Click or drag a file to this area to upload.

This upload is NOT compulsory. It is used to upload additional information, like an optometrist prescription in conjunction with the RX slip upload. Wait for upload to complete, then press the submit button.