CONSENT TO RECEIVE TELEHEALTH SERVICES

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(children 12 years or older, adults 18 years of age and older and of sound mind)

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Patient full names and surname* This field is required.

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Patient Identity Number

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Main member/Parent/ Guardian name and surname* This field is required.

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Main member/Parent/ Guardian Identity Number* This field is required.

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Patient Medical Scheme Name

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Medical Aid Number

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Patient/ Parent / Guardian address

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Patient/ Parent / Guardian email address* This field is required.

example@example.com

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Patient/ Parent/ Guardian mobile number:* This field is required.

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* This field is required.

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Signed at* This field is required.

Current location

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Date signed

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(which the Practice and Patient agree can be electronically affixed)* This field is required.

ClearPatient/ Parent/ Guardian signature

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Medical Aid Escalation process: Should you have any queries or complaints, or perceive that you have been misinformed with regards to your medical aid benefits, the suggested route for these to be lodged is the following:

1. Medical Scheme 2. Principle Officer 3. Council for Medical Schemes (CMS) at 0861 123 267 or visit www.medicalschemes.com

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Briefly explain* This field is required.Please indicate why you are concerned

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Attach supportive pic's or screenshots or documents.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

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Help Needed* This field is required.

Consultation for an existing problem

Schooling assessment follow-up appointment

New Patient schooling assessment

New Patient not previously seen by Dr. Flett

Urgent problem needing consultation for new problem

Emergency needing possible hospitalisation

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Schooling assessment consultations

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Preferred method of contact.* This field is required.Please keep checking your email or WhatsApp for the Zoom link

Telephonic

WhatsApp video call

Apple FaceTime

Zoom Video meeting

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