Confidential Patient Record

Confidential Patient Record
Personal Details
Full Name as per your Passport/Identity Document/Birth Certificate*

PrefixFirst NameMiddle NameLast Name
Maiden Name
Preferred Name
Birth Date*

MonthDayYear
Identity Number/Passport Number*
The purpose of providing this number serves as your unique patient identifier to encrypt and protect your confidential medical information and test results. We will not disclose the results of any investigations such a bloods, clinical images etc without proof the requesting person is the holder of this identification. An ID or passport number is also a mandated requirement for all prescriptions, according to the 2017 amendment of the General Regulations of the Medicines and Related Substances Act 1965 of South Africa, to ensure safe prescribing and reduce fraud/substance abuse.
Please upload a head and shoulders or ID/passport type photo of yourself, so that we can quickly remember you in future and put a face to your name. Even a quick selfie will suffice but no smiling or spectacles please.*

Contact Details

This information is used so that your doctor can contact you to check up on how you are recovering, share results of tests, dispense advice and prescriptions, serve accounts and from time to time, send practice updates. Please be advised that all communication is recorded and your information is held in the strictest confidence as per the The Protection of Personal Information Act (POPIA) of 2013.
Email*
Please ensure this email is private as confidential medical information may be shared to this address. Don't use your work email address!
Cell Phone Number*
Please enter a valid phone number and include your international code.
Physical Address (whilst) in South Africa *

Street Address

Street Address Line 2

CityState / Province

Postal / Zip CodeCountry
Postal Address if different to the above

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Which of Dr Cardoso's Newsletters would you like to recieve?*

Medical and Health Updates ie. current circulating illnesses; wellness and prevention advicePrimary Care Dermatology and Aesthetic Medical AdviceAllNone.

Your Next of Kin

MEDICAL PROXY
In the case of an emergency it is important for doctors to get hold of your Next of Kin, a trusted proxy who knows you and your wishes well and is able to assist your medical team in your care.*

Contact my Next of KinI do not wish to nominate a Next of Kin
You do not have to nominate a medical proxy but in an emergency, where you may be incapacitated and unable to make deicions for yourself, if you have not nominated a trusted person to stand by your side and in your stead and/or we are unable to get hold of them, then by default you leave all your decision making in the hands of the health care workers caring for you.

Should a person declare to be your next of kin, even if they can prove they are your mother/husband/daughter etc., if you haven't nominated them by name, it becomes extremely difficult for them become involved in your medical care meaningfully due to the legal bureaucracy that safeguards your confidential medical information and in stressful emergencies this creates immense strife.

If you attend our practice for cosmetic dermatological reasons, this is still a division of medicine and the aesthetitians work under the oversight of an onsight doctor every day. Although exceedingly rare, people can develop adverse reactions to any and all procedures including fainting, anaphylaxis (a very seriours allergic reaction), etc.
Your Next of Kin's Name and Surname
Net of Kin's Cell Phone number
Next of Kin's email address
What is your relationship to your next of kin?
You should not appoint anyone who provides you with health care or support services for compensation, unless you are sure there is no conflict of interest.
You have the option to nominate more than one Next of Kin who we can contact in an emergency should your primary proxy not be available.

I nominate one personI would like to list another person in case
Alternative Next of Kin Full Name
My Next of Kin may act:

Independently (Primary proxy is consulted first on your behalf and the alternative proxy is only reached if the first is unavailable)Jointly (Proxies have to agree on every decision yout medical team makes, this can cause significant delays as no action can be done until they agree)
Having proxies act jointly means they must agree on all decisions before action can be taken. This can often lead to disagreements, misunderstandings and family fallouts, not to mention the risk of time-consuming delays in your medical care. Having them act independently means that if the person you named as Primary Medical Proxy is unavailable or unable to act on your behalf, the person you named as Alternate Medical Proxy is automatically authorised to assume the duties.

It is often recommended to have your proxies act independently.
Would you like us to send you more information to think about when you're ready? Should you ever require other people to step in and you help you in an emergency, we'll then know what is important to you, your values and who to share that with.*

YesNot right now.
When you are ready see the Planning an Advanced Directive Guide provided by Dignity SA.

Every person deserves to face their darkest moments with dignity and choice. Although death is an inevitable part of life, many of us are reluctant to face the fact that we're not going to live forever and plan for our end-of-life care. Thinking about your end-of-life choices today, even as a young person, can improve your quality of life in the future and ease the burden on your family.

You can always change your mind on these decisions.

This is important, any instructions you give orally will over-ride previously written instructions provided you are competent when you express them. It's a good idea to review your Advanced Directive annually.

Medical Insurance and Payment Details
Doctors’ in South Africa are free to levy fees for services rendered to patients according to what they regard as appropriate based on their overheads. Professional fees charged by doctors and the "benefits" of your individual insurance scheme package may differ. I hold no contract with any insurance scheme. There is no industry standard "medical aid rate", each scheme determines their own "level of benefit" they are prepared to pay for services rendered.
Do you pay to your account privately or do you plan on submitting your invoice to a third party funder/insurer for reimbursement after your appointment? *
Your Insurance Scheme
Your Insurance Plan
Insurance Membership No.
Your dependant code
Main Member is usually 00, dependents are often then given subsequent numbers i.e. 01,02 etc.
Full Name of the Main Member, if not you.
Main Member Details

If you are a dependent on another person’s medical insurance, they will receive the invoice and it is their ID number or date of birth that unlocks the invoice. If you do not provide this information your insurance scheme may deny or delay payment of your claim. Please be aware that if you are a dependent of another person's insurance, your funder may detect their details and automatically address the invoice to the main member. It may be possible for the main member to access codes that reveal confidential diagnoses about you. If you prefer this information is not sent to the Main Member of your plan, you may need to pay privately.
Main Member's ID no.:
Main Member's Contact No.
Main Member's email address:
Fees for medical services are to be paid immediately. Consulations are booked for a preset amount of time which usually allows for the provision of care for one medical problem, a pro-rate fee may apply based on additional length of time, complexity and extent of advice.

Please discuss treatment costs BEFORE services and professional fees are rendered. My professional and practice fees exclude the fees and costs charged by other health care providers, such as pathologists and radiologists such as Pathcare, Lancet, Morton & Partners etc., or other specialists and allieds, for their health services.

My accountant will furnish you with an invoice within 10 working days of yout appointment. To assist you, we will include the Medical Insurance details your have provided us in this form on your invioce, to expediate the submission process to your funder so they can re-imburse you based on the BENEFITS they have provided for you.

If you are a dependant, your account is automatically adressed and emailed to the main member.

Medical schemes and their administrators do not have justifiable grounds to inform patients that a doctor’s costs are excessive according to their BENEFIT structure as there is no industry standard for doctor’s professional fees; all funders have different “medical aid rates”; and funders provide BENEFITS to patients according to the package options selected by patients whilst doctor’s charge professional fees for services rendered to patients.
I agree to the immediate and direct payment to Dr Serena Cardoso for her professional and/or practice fees provided to my dependants and/or I. Fees which may be amended from time to time. Notwithstanding the fact that my dependants and/or I may be a member of a Medical Aid Scheme, whose rules and benefits I am obliged to be fully acquainted with. I accept full liability for accounts rendered and shall be responsible to personally lay and pursue any complaint against my medical aid scheme and will resolve disputes without the intervention of Dr Serena Cardoso or the practice.*

Yes.

Terms and Conditions

I understand all the information requested in this form, declare it to be true and consent to the disclose of this information to Dr Serena Cardoso and her clinical team who will protect this confidential data with the utmost privacy as they are legally, duty and ethically bound to protect. In addition, I have read the terms and conditions below.
Your Signature*

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Thank you for the time you have taken in your day to complete this form, I know it's tedious but it serves to help me provide you with more efficient clinical care. A copy will be sent to you for transparency.

Yours faithfully,

Dr Serena Cardoso
DateTime
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Confidential Patient Record

Personal Details

Contact Details

Biopsychosocial Information

Sexual Health:

Your Next of Kin

Medical Insurance and Payment Details

Main Member Details

Terms and Conditions