Patient Information and Terms and Conditions for Prof Chrysis Sofianos

Patient Information | Terms and Conditions | Social Media Consent | POPI Consent

Please fill out the fields below. Completion of this prior to your appointment speeds up the registration process immensely.

Do not hesitate to contact our office on 010-500-5151 or info@cs.surgery should you have any questions.
Main Member Information / Person Responsible for Account
- This is the Main Member of the Medical Aid Plan or the Person who will be responsible to pay for the account.
- If the main member or main member's scheme declines to fund the care in full, or at all, the adult patient is legally liable for the full costs of the care received.
ID or Passport Number*
Title
Full Names*
Surname*
Gender*

MaleFemale
Date of Birth*

YearMonthDay
Date
Cellphone Number*
Home Phone Number
Work Phone Number
Email Address*
example@example.com
Physical Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Is the Physical Address and Postal Address the same?

Yes
Postal Address

Postal Address Line 1

Postal Address Line 2

CityState / Province

Postal / Zip CodeCountry
Employer
Occupation*
Medical Scheme Information
Are you on a Medical Aid or Insurance?*

YesNo
Private Patient
Medical Scheme*
Medical Scheme Plan/Option*
Medical Scheme Membership Number*
Do you have Gap Cover?

YesNo
Patient Information
Is the Patient and the Main Member / Person Responsible For The Account the same person?

Yes
ID or Passport Number
Title
Full Names
Surname
Gender

MaleFemale
Date of Birth

YearMonthDay
Date
Cellphone Number
Home Phone Number
Work Phone Number
Email Address
example@example.com
Chronic Medical Conditions
Do you have Diabetes?*

YesNo
Do you have Asthma?*

YesNo
Do you have Epilepsy?*

YesNo
Do you have Hypertension?*

YesNo
Do you have any Allergies?*

YesNo
Specify the Allergies You Have
Do You Smoke?*

YesNo
For how many years have you smoked?
What type of product do you smoke?
E.g. Cigarette, Cigar, Vape etc.
Referral
Were you referred by another doctor/health professional to Prof Sofianos?*

YesNo
Who is the referring doctor/health professional?
Who is your usual or family doctor (GP)?*
How did you learn about Prof Sofianos?
Next of Kin
This is the person with whom we are authorised to speak to about your healthcare / outcome of your procedure.
Full Name*
Relationship to Patient
Email Address
example@example.com
Contact Number*
Consent to Photographs and Videos
To render a complete and effective service, Prof Sofianos and his staff will collect and retain photographs and videos to document your physical appearance, wounds and/or other body parts as necessary. This will be performed in line with the following -
- Photographic Documentation: Photographs and videos are taken during the consultation, treatment, and follow-up process to document physical appearance and monitor progress accurately.
- Use of Recording Equipment: Different types of devices may be used to collect these photos, including mobile phones, cameras, or other recording equipment, all managed securely and professionally.
- Essential for Treatment Planning: These images help assess your unique needs, plan procedures, and ensure the best possible outcomes.
- Secure Storage: All photographs and videos are securely stored in your medical chart, adhering to strict confidentiality and data protection standards.
- Sharing for Service Delivery: In some cases, images may be shared with medical aids or other healthcare professionals as required to provide comprehensive care and facilitate approvals or collaboration.
- Patient-Centred Approach: The collection of images is handled respectfully and professionally, ensuring your privacy and comfort at every stage of the process.
Social Media Consent

In addition to the above, please read through the following and select an option for the use of your photographs and videos in social media.
Social Media Consent for Photographs/Videos*

I OPT OUT: I do not want my photographs to be used for advertising or marketing but I understand that these will still be collected and retained as part of my medical record and may be shared with your medical aid and other healthcare professionals to render care or for education within the practice.EDUCATIONAL PURPOSES ONLY: Photographs as well as details regarding procedures performed may be used in presentations, journal articles, and scientific publications to educate other healthcare professionals.PRACTICE WEBSITE ONLY: Photographs as well as details regarding procedures performed may be used on our website without disclosure of personal information.ALL MEDIA EXCLUDING SOCIAL MEDIA: Photographs as well as details regarding procedures performed may be used in print or broadcast media without disclosure of personal information.ALL MEDIA INCLUDING SOCIAL MEDIA: Photographs as well as details regarding procedures performed may be used on social media sites, including but not necessarily limited to Facebook, Instagram, Snapchat, Twitter, RealSelf, Whatsapp and other outlets.
- Click here to view the full Social Media Consent.
Practice Terms and Conditions
- Click here to view the Practice Terms and Conditions
Consent to Process Personal Information in line with POPI Act
- Click here to view Consent form to Process Personal Information in line with the POPI Act
Declaration
- I confirm that the information I have given is true and correct.
- I will notify the practice of any changes to my medical aid or contact details before proceeding with any further consultations or procedures.
- I confirm I have read the attached Practice Terms and Conditions and accept them in full.
- I confirm I have read the attached Consent to Process Personal Information and accept it in full.
- I confirm that I have read the Consent to Social Media and accept that photographs and/or videos will be collected and retained in my medical record at the minimum.
Date

YearMonthDay
Date
Hour Minutes
Signature

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Patient Information | Terms and Conditions | Social Media Consent | POPI Consent

Main Member Information / Person Responsible for Account

Medical Scheme Information

Patient Information

Chronic Medical Conditions

Referral

Next of Kin

Consent to Photographs and Videos

Practice Terms and Conditions

Consent to Process Personal Information in line with POPI Act

Declaration