CONSENT TO RECEIVE TELEHEALTH SERVICES

( Adults 18 years of age and older and of sound mind. Consultations from Birth to any age)

Patient full names and surname*

Patient Identity Number

Main member/Parent/ Guardian name and surname*

Main member/Parent/ Guardian Identity Number*

Patient Medical Scheme Name

Medical Aid Number

Patient/ Parent / Guardian address

Patient/ Parent / Guardian email address*

example@example.com

Patient/ Parent/ Guardian mobile number:*

Terms and conditions to receive Telehealth

AGREEMENT TO TELEHEALTH&#13;&#10;&#13;&#10;I, the Patient/ Parent/ Guardian hereby agree:&#13;&#10;&#13;&#10;1.To be serviced by the Practitioner from this Practice, with whom I have established a practitioner-patient relationship (unless for telepsychology or telepsychiatry, where new patients could be helped in this manner), by means of electronic media (, Zoom or&#13;&#10;&#13;&#10;similar; and/or by telephone and/or by WhatsApp Call or FaceTime call and/ or as&#13;&#10;&#13;&#10;authorised by the Health Professions Council of South Africa (HPCSA) for the period of the Covid-19 Lockdown.&#13;&#10;&#13;&#10;2.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 therefor release the Practitioner form being legally liable for this.&#13;&#10;&#13;&#10;3.There is no subscription required when using the electronic platforms mentioned above, such as costs for the Applications (‘Apps’) used, 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, telephone and/or computer, etc.&#13;&#10;&#13;&#10;4.That the Practitioner may encourage me to present myself for a face-to-face consultation 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.&#13;&#10;&#13;&#10;5. That I will be billed for a consultation at the standard rate charged by our practice that may change from time to time. Standard rate: &#13;&#10;R 1385 to be paid for routine  telemedicine or telephonic consultation( colds, flu,stomach complaints etc)&#13;&#10;R1850 to be paid for after-hours telemedicine consultation( Weekends/ Public Holidays, weekdays 5pm-8am)&#13;&#10;For schooling related/ADHD follow-up assessments the consultation fee is to be determined by our staff and discussed with you  at the time of consultation.&#13;&#10;I also understand that, due to the nature of the current pandemic, that the Practitioner may have to give urgent attention to their patient, and/or have to move my appointment to a later or earlier time or day.&#13;&#10;&#13;&#10;6. That my medical scheme may or may not cover the costs of this care( above fee is based on medical Aid payment by Discovery Medical Aid). I undertake to cover any shortfall that my scheme does not cover, which may be the full amount. However, I understand that the HPCSA allows such care during the time of the Covid-19 Pandemic, and that certain services must be funded by my scheme in full.&#13;&#10;&#13;&#10;7. To record-keeping of the sessions, i.e. the Practitioners notes, which are required by law, and with my prior consent, to the recording of the live sessions as video and sound recording.&#13;&#10;&#13;&#10;8. That the service may have limitations relating to technology, such as data and internet failures (e.g. dropped calls or bad reception&#13;&#10;&#13;&#10;9. 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 sessions with me (in person or through 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; c. 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, he/she 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.&#13;&#10;&#13;&#10;I, therefore, freely and voluntarily consent to this service, and I understand the implications thereof, including the costs related to it.

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Signed at*

Current location

Date signed

(which the Practice and Patient agree can be electronically affixed)*

Patient/ Parent/ Guardian signature

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

Briefly explain*

Attach supportive pic's or screenshots or documents.

Browse Files

Help Needed*

Consultation for an existing problemSchooling assessment follow-up appointmentNew Patient schooling assessmentNew Patient not previously seen by Dr. FlettUrgent problem needing consultation for new problemEmergency needing possible hospitalisation

Schooling assessment consultations

Preferred method of contact.*

Zoom Video meetingother