Meagan Atcheson BSc (Wits) B. Med Sci (Hons) (UCT) Practice No: 0735361
I understand that the above patient has been seen to by Ms. Meagan Atcheson, Registered Dietitians, for nutritional assessment and therapy. Nutritional Therapy may include direct interaction such as Nutrition Education and Nutritional Support. Nutritional Therapy may also involve indirect interactions, such as: The calculation, prescription, monitoring and ordering of specialized medical nutrition, in the form of intravenous nutrition, enteral feeds or oral nutritional supplements. The design of meal plans Writing of motivation letters to medical aids Liaison with other members of the medical team and catering about my nutritional treatment plan. I consent to nutritional assessment and therapy as specified above. I confirm that the billing procedures of this practice has been discussed with me. I undertake to settle the full cost of treatment and to pay for any treatment not covered by my medical aid. I understand that I have the right to decline treatment offered to me at any stage of the nutritional treatment offered to me. I consent to the collection, storage, use and processing of my personal information (including special personal information) for the purpose of this treatment. I consent to you disclosing such information to third parties involved in the treatment and aspects incidental to the treatment, such as implementing the treatment plan or collecting monies. I understand that my nutritional care may be taken over by other dietitians from time to time. I agree that you will not be held liable for the disclosure of personal information in good faith to third parties for the purpose of and in relation to the treatment. No further specific consent needs to be obtained for the transfer of such information to a third party.
Should my account be submitted to my medical aid, I give consent for it to be done electronically. I understand that on doing so my information, including my ICD 10 (diagnostic) codes are therefore shared with a third party. I consent that information relevant to the billing process, will be given to your account manager, Ms. Nicolene Fox (e-mail: meagandietician@nlconsultings.co.za who will contact medical aids and relevant persons related to the account, on my behalf.
I confirm that I understand the terms of this consent and that this consent was not given under duress.