Patient Registration Form - Dr. Elna Rudolph (JHB)

Contact Details:
Mobile Phone Number*

PrefixNumber
Landline Number

Area CodePhone Number
Street Address:

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Postal Address:*

PO BOX

CityState / Province

Postal / Zip CodeCountry

Do you have a Medical Aid*

YesNo
Medical Aid Details:
Medical Aid Name:
Medical Aid Plan:
Medical Aid Number:
Are you the Main Member?

YesNo
Main Member Name:

First NameLast Name
Main Member ID Number:
Dependant 1:

First NameLast Name
Dependant 2:

First NameLast Name
Dependant 3:

First NameLast Name
Dependant 4:

First NameLast Name

Please upload a copy of your ID document and medical aid card by dragging and dropping the files into the box below. Should you have trouble completing this step, please click next, but please then remember to bring your ID and medical aid card with you to your first appointment.

Next of Kin Details
Name*

First NameLast Name
Telephone Number*
How are you related to this person?

ParentSpouse/PartnerSiblingChildFriendColleagueAunt/UncleOther
If Dr Elna Rudolph and Associates Inc needs to contact me, and has not been able to reach me for a reasonable amount of time, I agree and give consent that they may contact my next of kin as listed on my registration form in order to reach me. Under no circumstances will any personal medical information be shared with this person without my consent. I agree and understand that should Dr Elna Rudolph and Associates Inc or its representative(s) need to contact my next of kin, the person making the call, will need to clearly identify themselves in order to receive relevant information from my elected next of kin.*

I have read, understood and accepted these terms and conditions.

Consent: Medical
CONSENT TO INFORMATION BEING SHARED:

• I understand and agree that the practice issues invoices, statements and prescriptions that include diagnostic and/or procedural information such as procedural tariff codes and/or ICD10 codes, which indicates my diagnosis, according to legal requirements prescribed by Medical Schemes provided for in the Medical Schemes Act No. 131 of 1998. I understand that this means that if I submit invoices to my medical aid they will have access to the diagnostic and/or procedural information on the invoice. I understand that should I decide not to disclose my diagnosis to my Medical Aid, I should refrain from submitting such invoices, statements and prescriptions to my Medical Aid for claims purposes. I acknowledge that I am welcome to discuss my diagnoses and diagnosis code (ICD10 Code) with my doctor.

• I understand and agree that if I am not the main member on my Medical Aid policy, submitting invoices and statements from the practice as mentioned above, it is possible that diagnostic and/or procedural information such as procedural tariff codes and/or ICD10 codes, which indicates my diagnosis, can be disclosed to the main member on my Medical Aid policy.

• I understand and agree that diagnostic and procedural information (as well as any related photographs) related to my treatment may be utilised for practice statistical, research and/or teaching purposes. All such information will be dissociated from my personal patient information. Informed consent will be obtained by the practice if any of my information is required for clinical trials or research projects.

• By providing my medical aid detail, I agree and authorise the practice to provide any information concerning my treatment at this practice, including but not limited to current conditions/comorbidities to my medical scheme, their managed healthcare organisation and/or their respective agents dealing with my treatment. Should any of the aforementioned parties also be my employer, then I understand that the information may also be available to my employer.

CONSENT TO ALTERNATIVE, UNREGISTERED or COMPOUNDED TREATMENT:

• I understand and agree that my doctor might prescribe a treatment for me that might be seen as alternative. It might also not be registered for use in males or female in South Africa. It might be so-called “off-label” medication, meaning that it is not used for the purpose that it was registered for. The treatment might also be compounded by a compounding pharmacy according to a specific recipe prescribed by my doctor. I am welcome to ask my doctor whether the suggested treatment is seen as conventional or alternative. Conventional medication is always preferred, unless the patient only wants natural, herbal or bio-identical treatment or if there is no conventional/registered option available for the specific condition. I am welcome to ask questions about my prescribed treatment until I am satisfied that I have enough knowledge to make an informed decision about it. My doctor will offer all available treatment plans for my condition and might make suggestions, but it is my right to accept or refuse any treatments. The employees of Dr Elna Rudolph and Associates Inc commit to not being offended if I ask questions and request more information.

• I understand and agree that I should take medication exactly as it is prescribed by my doctor. If I decide not to take certain treatments due to side-effects or for any other reason, I run the risk of serious complications, varying in severity, but can include cancer and death. If I have difficulty taking my medication as prescribed, it is recommended that I rather contact my doctor.

CONSENT TO TELEHEALTH (Where applicable):

I acknowledge that some of the employees of Dr Elna Rudolph and Associates Inc are available for face to face consultations. If, however, I decide to consult them via a telephonic or online appointment, I consent to the following:

- I understand that this platform will be used to render healthcare services to me, and that the usual consent processes will be followed (i.e. I will be informed of my health status, as well as the benefits, risks and implications of the care). I understand that I can opt out of receiving care at any stage, but acknowledge that it may not be in my best interest and I therefore release the Practitioner from legal liable for such an opt-out.

- There is no subscription required for using the electronic platform (Whereby.com or Healthspace.co.za), but I understand that I will carry my own costs of any infrastructure and/or running costs associated with such service being rendered e.g. the data used, the telephone and/or computer, etc.

- The employee of Dr Elna Rudolph and Associates Inc may encourage me to present myself for a follow-up face-to-face consultation with themselves or at a healthcare facility close to me if he/she is in doubt that the telehealth consultation is in my best interest, provided that it would be safe for me, the Practitioner and others, to do so.

- That I will be billed for a consultation at the rate set out in this document and updated every year on the 1st of March.

- That my medical scheme may, or may not cover the costs of this care. I undertake to cover the full amount.

- To record-keeping of the session via an electronic medical record system. (Please note: The Employees of Dr Dr Elna Rudolph and Associateds Inc cannot consult you online/telephonically if you do not consent to the use of the Healthspace electronic medical record system.)

- That the service may have limitations relating to technology, such as data- and internet failures (e.g. dropped calls or bad reception).

- That, although the Practitioner will adhere to the existing rules relating to confidentiality:

a. I understand that I must take the necessary precautions at home to ensure my confidentiality during telehealth service provision;

b. I understand that, should I want a family member, caregiver, parent or other person to attend the session with me (in person or through a remote internet connection), I will provide my written consent to such attendance prior to the consultation. I understand that without this, should such a person be in attendance, the engagement may be cancelled or rescheduled;
Please click here to indicate that you have read, understood and agreed to give Medical Consent:*

I have read, understood and accepted these terms and conditions.

Consent: Fees & Charges
Refer to consultations page on the My Sexual Health Website for the latest rates:

https://mysexualhealth.co.za/pages/consultations

For futher information:

Email: reception@mysexualhealth.co.za

Phone or whatsapp: +27 (0)61 302 6730

Please note:

- Dr Elna Rudolph and Associates Inc does not charge medical aid rates

- All online and telephonic appointments have to be paid prior to the consultation. If not, the appointment will be cancelled.

- Our prices are updated on the 1st of March each year

- If you require a procedure, you are welcome to contact the office to request a quotation (reception@mysexualhealth.co.za)
Please click here to indicate that you have read, understood and agreed to the fees & charges:*

I have read, understood and accepted these terms and conditions.

Consent: Terms & Conditions
CONSENT TO THE TERMS AND CONDITIONS OF DR ELNA RUDOLPH AND ASSOCIATES INC:

• All appointments including telephonic appointments must be confirmed at least 24 hours before hand. Appointments that are missed and was not cancelled more than 24 hours in advance, will be charged at the full appointment fee. (Please note: medical aids do not cover missed appointments, so this amount will be for your own account and this arrangement is valid for all future appointments.)

• We are a CASH practice. This means you have to pay for your consultation on the day of your appointment or before your appointment. We accept cash, cards, EFT payments, bank deposits and vouchers from MySexualHealthSHOP prior to or directly after your appointment.

• Please note: Procedures, consumables, medication and blood tests are not included in these rates. A pap smear or rectal examination is included, but not the laboratory fees. Please inform your doctor at the start of the consultation if you would like a pap smear/prostate examination.

• Invoices: Your invoice might not be generated by the receptionist and might also not be generated immediately after your appointment - she will however receive your payment and supply you with a receipt at that time. You can expect to receive your invoice within one week of your consultation via email, but there might be exceptions to this due to circumstances beyond our control. Please contact us directly at accounts@MySexualHealth.co.za if you would like to get your invoice urgently. Keep in mind that you have up to four months to submit your invoice to your medical aid.

Medical Aid:

• Dr Elna Rudolph and Associates Inc does not submit invoices/statements for claims to medical aids on your behalf. You will be responsible for lodging a claim with your medical aid, and the responsibility for such a claim does not lie with Dr. Elna Rudolph and Associates Inc. You will be invoiced directly and you can then claim back a portion of the fee from your medical aid according to your specific and available cover.

• It is your responsibility to submit the invoice together with the proof of payment to your medical aid for them to reimburse you. Should your medical aid reimburse Dr Elna Rudolph and Associates Inc after you have settled your account with us, or there is a credit on your account for any reason whatsoever, that amount will stay in credit on your account. Should you require a refund for amounts credited to Dr Elna Rudolph and Associates Inc in excess of your outstanding balance with us, or your Medical Aid requested a refund from us, an administration fee of R50 will be charged to recover banking and administration fees. The onus remains on the patient to inform us of any payments that may have erroneously been paid into our account.
I agree and acknowledge that these fees must be paid with cash, a debit or credit card or via EFT directly after the consultation on the day of the appointment or before the appointment if the appoint is online or telephonic.*

I have read, understood and accepted these terms and conditions.
I acknowledge that if I do not cancel my appointment with Dr. Elna Rudolph and Associates Inc at least 24 hours in advance, I will be charged for the full appointment. I understand that medical aids do not cover missed appointments, so this amount will be for my own account, and that this arrangement is valid for all my future appointments.*

I have read, understood and accepted these terms and conditions.
I agree and acknowledge that I am responsible for lodging a claim with my medical aid, acknowledging that the responsibility for such a claim lies with me and not with Dr. Elna Rudolph and Associates Inc. The medical aid will not cover the full charge for my appointment, but might reimburse at least a portion of the payment to me, depending on my specific and available cover.*

I have read, understood and accepted these terms and conditions.
I acknowledge that I am entitled to request a detailed costing estimate related to any planned procedure/treatment at the practice. It is my responsibility to understand my medical aid benefit plan, and to know if written referrals / authorizations are required for consultations or procedures, and what services are covered and available on my policy. Obtaining prior authorisation for services from my medical aid does guarantee its payment. *

I have read, understood and accepted these terms and conditions.
I accept that I am fully responsible for payment for services rendered and should I not pay timeously as set out in my invoice or statement, I understand that I will be liable for debt recovery costs on an attorney and own client scale. *

I have read, understood and accepted these terms and conditions.

Consent: Use of Electronic Health Records
By giving consent herewith, I agree to let Healthspace (PTY) Ltd ("Healthspace"/"we/us") retain and/or host my personal information and medical history on our Website http://www.healthspace.co.za and consent to my personal information and medical history being viewed by my healthcare professional(s).

[Complete terms and conditions and privacy policy are available at https:/www.healthspace.co.za/termsandconditions.html]

1. • My Personal Information - These are items of personal information that will be retained by Healthspace and viewable on the Website by my healthcare professional

     • My Electronic Health Record - These are the details of my medical history that I consent to let my healthcare professional enter on my electronic health record on the Website:

1.1 My medical condition: My general state of health, as well as any conditions I suffer from, including chronic conditions;

1.2 Test results: Any test results relating to my medical condition;

1.3 Relevant information: Any other information my healthcare professional may deem as relevant in helping me to manage my medical condition.

2. To whom does Healthspace disclose this information?

2.1 Healthcare Professionals: My healthcare professional has access to my personal and medical information. In addition you may authorise other registered healthcare professionals registered on the Website to have access to my personal and medical information on the Website; and

2.2 Healthspace: as the operator of the Website on which my personal and medical information is stored, they have access to my personal and medical information.



3. What Healthspace does with this information?

3.1 The personal and medical information provided by me and my healthcare professional is used to create a "Patient Profile" that allows both me and my healthcare professional to access and view my patient file information stored on the Website which may include but is not limited to information relating to:

3.1.1 my diagnosis and/or medical condition(s);

3.1.2 treatment provided to me by my healthcare professional;

3.1.3 medicines prescribed to me by my healthcare professional;

3.1.4 clinical notes drafted by my healthcare professional; and

3.1.5 results of any medical tests.



By marking the appropriate button below I confirm that:

1. I agree to and understand the terms of this Consent Form.

2. I give consent that a "Patient Profile" may be created for me by MySexualHealth with a generic password

3. I confirm that I will change this generic password for my "Patient Profile" upon receipt of my registration email to ensure the security of my medical information.
Please note: This is the system that Dr Elna Rudolph and Associates Inc. use for all their medical records. This system uses the same type of security that banking websites and other secure websites use known as a Premium EV SSL Certificate. You can verify this by looking at the web address which starts with https:// instead of http://, the lock displayed in the address bar, and the security stamp at the bottom of the page, which all indicate that it is a secure site.

We are unable to provide online or telephonic consultations or repeat prescriptions to patients who do not want to be registered on this electronic health record system.
I agree to the terms and conditions above*

Yes, please create a "Patient Profile" for meNo, please do not create a "Patient Profile" for me
Please click here to indicate that you have read and understood that should you choose not to make use of our electronic medical record system, neither you nor your medical professional will have access to your medical information online. Your appointment time will be reduced by 5 to 10 minutes in order for your doctor to be able to peruse your medical records on file. Should you require any medical information, feedback or repeat prescriptions, your doctor will not be able to access your information online nor be able to send you electronic scripts and letters. This is really not in your best interest and we strongly advise you to make use of our highly confidential and reputable electronic medical record system (Healthspace)*

I have read and understood this information.

Appointment Arrangements:
• Please scan and email your medical aid card and ID to us at reception@mysexualhealth.co.za before your visit if you did not upload it onto your registration form. It is your responsibility to ensure we have your correct information and an up-to-date copy of your medical aid card and ID at all times. It is therefore your responsibility to update your personal information as soon as there is a change, and if you fail to provide us with the correct updated information Dr Elna Rudolph and Associates Inc will be indemnified against any damages should a breach of privacy occur

• You must confirm your appointment with us at least 24 hours or more before the time via email at reception@mysexualhealth.co.za. If you do not confirm your appointment, it may be cancelled in order to accommodate a patient on our waiting list. If you don't confirm, we will assume that you are still coming and you will be charged for that appointment.

• You will receive an email from us stating the exact date, time and venue of your consultation, requesting you to confirm your appointment. If you did not received it, please insist on one. If there are any discrepancies between the email you received and what you were told at the time you made your appointment, please email reception@mysexualhealth.co.za or phone +27 61 302 5730 to clear up the discrepancies. There is nothing more frustrating for you and for us than for you to show up at the wrong time or place!

• Please let us know if you had any blood tests done recently, and obtain a copy of your results from the lab where the tests were done or from the doctor that first ordered the tests. Please make sure that you email these results to us before your appointment at reception@mysexualhealth.co.za. Please follow up with us the next day to make sure we received your results and uploaded them onto your profile to ensure the best use of your time during your appointment, especially if your tests were done at a lab other than Lancet. If you cannot email them, please bring them with you to your appointment.

• We strongly advise that you have blood tests done before you see your doctor. Please refer to the form “Blood Tests Required” to determine what the right tests will be for you. Please note that if tests are ordered during your consultation, a separate Telephonic or Face-to-Face consultation must be scheduled to discuss the test results, which will be charged at the standard rates. In some cases, where results are completely normal and no further actions are required, no follow-up consultation will be necessary. Please note that we do not operate on the "no-news-is-good-news" principle. We always inform patients of their test results. If you do receive feedback from us within one week of sending in a sample, please contact the office to follow-up your results. We will always inform you about normal results via email and schedule follow-up appointments to discuss abnormal results.

• Should you be instructed to go for blood tests after your first appointment, and you decide not to use Lancet Laboratories, please phone our rooms after 3 days, or before your appointment (whichever is applicable) to check if we received your results and uploaded them onto your profile.

• Arrive at least 10minutes before your appointment please if you have a face-to-face consultation. If you suspect that you might have an infection, please ask the receptionist for a disposable cup to provide a urine sample.

• We do respect your time and it is not our intention to keep you waiting, but it is sometimes unfortunately unavoidable.
Please click here to indicate that you have read, understood and agreed to these appointment arrangements:*

I have read and understood this information.

I understand and agree that the terms and conditions in this document may be amended by MSH/Dr Elna Rudolph and Associates Inc from time to time without notice.*

I have read, understood and accepted these terms and conditions.
Should be Empty:

Dr Elna Rudolph and Associates Inc.

Contact Details:

Medical Aid Details:

Next of Kin Details

Where did you hear about us?

Consent: Medical

Consent: Fees & Charges

Consent: Terms & Conditions

Consent: Use of Electronic Health Records

Appointment Arrangements: