• 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.
• 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.
• 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.
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. Dr Jireh Serfontein commits 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, the Patient, hereby acknowledge that Dr Jireh Serfontein is available for face to face consultations. If, however, I decide to consult her 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.
- Dr Jireh Serfontein may encourage me to present myself for a follow-up face-to-face consultation with herself 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 2021. I understand that, due to the nature of the current pandemic, that the Practitioner may have to give urgent attention to other patients, and/or have to move my appointment to a later or earlier time or day.
- 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: Dr Jireh Serfontein 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;
- I understand that, and agree that, should the practitioner believe that I may have been exposed to Covid-19 and/or do have Covid-19, she/he would refer me for tests, and I understand that the results of such tests must be reported, by law, to the NICD – National Institute of Communicable Diseases. I, therefore, freely and voluntarily consent to this service, and I understand the implications thereof, including the costs related to it. Signed at (place) on (date). Patient signature, which the Practice and Patient agree can be electronically affixed