• 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 Elna Rudolph 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 Elna Rudolph 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 Elna Rudolph 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 Elna Rudolph 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, s/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
New patient – 60 minute consultation - R2550
New patient – 30 minute consultation - R1600
30 minute follow-up consultation: R1200
15 minute follow-up consultation: R750
- PRESCRIPTION R395 (only available to known patients):
(The POP comes to us directly, no need to send it through.)
BANKING DETAILS:Dr Rudolph Govender and Associates IncStandard Bank | Branch Menlyn (012345) | Account no: 012 668 400 |Reference: Name and Surname
(Please send through the POP if you have used the EFT option)
- Dr Elna Rudolph does note charege 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 (firstname.lastname@example.org)
CONSENT TO THE TERMS AND CONDITIONS OF DR ELNA RUDOLPH:
• 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.
• MSH/Dr Elna Rudolph 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 / MySexualHealth.co.za. 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 MySexualHealth.co.za 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 with MySexualHealth. You will be informed of such credit upon receipt of an account statement from MySexualHealth.co.za, or upon your enquiry. Should you require a refund for amounts credited to MySexualHealth.co.za 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 MySexualHealth.co.za of any payments that may have erroneously been paid into our account.
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).
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 uses for all her 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.
Please consider carefully the ramifications of not allowing us to utilise this tool.
• Please scan and email your medical aid card and ID to us at email@example.com 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 MSH/Dr Elna Rudolph 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 firstname.lastname@example.org. 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 email@example.com 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 firstname.lastname@example.org. 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.