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Patient Information

Kindly complete and submit the form below. All fields marked with * are mandatory

Patient Information Intake Form


Please complete the information of the patient


Please complete the information of the main member


Please complete all relevant contact information


Detailed of your medical aid scheme (if applicable)


Details of your next of kin

Terms and Conditions

 Read this before signing form

Your right to privacy and confidentiality is protected by South African Legislation including the South Africa Constitution, the National Health Act, the Mental Healthcare Act and The Protection of Personal Information Act (POPIA). You are therefore requested to provide this practice/clinic/hospital with consent to treatment and consent to disclosure of information. Said information shall be utilized to serve as motivation for payment by medical schemes and shall be utilized to monitor your progress and care.

Please read through below and complete.
1.I am twelve (12) years old or older, and of sound mind and sufficiently mature to provide voluntary consent to treatment.
2.I hereby provide my voluntary consent to treatment by the duly qualified and authorized doctor and/or staff of Dr Melané van Zyl andunderstand that such treatment may have risks.
3.I understand that I may withdraw my consent, which is my right, at any time of my choosing, and will inform this practice/clinic/hospital ofsuch withdrawal of consent immediately. Without derogation of the practice/clinic/hospital’s record keeping obligations under law, I mayobtain a copy of my records taken by the respective health practitioner, or in the event of furtherance of my medical interests, such asconsultation with another health practitioner, the original record taken by the health practitioner.
4.I voluntarily consent to provide personal information to the practice/clinic/hospital including my name, ID number, exact physical address,contact information(email and telephone, sexual orientation, ethnic or social orientation, age, religion, well-being, physical and mentalhealth, culture, financial information and medical aid information; all the aforementioned relating to myself as an identifiable living naturalperson (“Personal Information”), provided that the practice/clinic/hospital; treats this Personal Information as confidential and that thepractice not pass on this Personal Information to third parties except as necessary for medical scheme claim purposes as per paragraph6 and as per paragraph 9,10 below .
5.I voluntarily consent to the practice/clinic/hospital disclosing information regarding my medical history, medical condition, suburb/town/cityof residence or employ, diagnosis, prognosis, treatment, improvement in diagnosis and recovery, including ICD 10 Codes (“the MedicalInformation”), to my medical aid, and I understand that such disclosure to my medical aid may result in a breach of my confidentialPersonal Information. I further understand that my Personal Information as it relates to my health may be processed by medicalprofessionals, health care institutions or facilities or social services which is necessary for my proper treatment and care and or for theadministration of the institution and or medical practice in accordance with section 32 of POPIA.
6.I understand and consent to my Personal Information and Medical Information in paragraph 4 and 5 being captured electronically ontoOutcomesIT patient record management database belonging to Outcomes IT (Pty) Ltd, which database being hosted on a server in SouthAfrica, and that the practice/clinic/hospital has satisfied itself that all reasonable measures have been taken by OutcomesIT to ensure thatsuch electronically captured Personal Information and Medical Information remains secure and confidential at all times.
7.I shall provide a full medical history to the clinic/practice/hospital including all medical conditions which I have or have had, and any medicine that I have or am taking.
8.I voluntarily provide my consent to the practice/clinic/hospital to arrange for, and or provide, as necessary, emergency medical treatment in the event it is required or deemed to be required.
9.I voluntarily consent that the practice/clinic/hospital may provide the Medical Information to other registered healthcare practitioners as registered under the Health Professions Act No. 56 of 1974 (as amended) for referral reasons and or social workers as registered under the Social Service Professions Act and or nurses as registered under the Nursing Act No 33 of 2005; all of whom shall be involved in the management of my health and medical care.
10. I voluntarily consent to my Medical Information being used for research/study/statistical analyses/funding motivation purposes and may be passed on to third parties as de-identifiable data or anonymized data (“Anonymized Information”). (i.e. no personal identifiable information including name, ID number, exact address, telephone number, email and other contact details will be passed on to any third parties for any reason whatsoever.)
11. I understand that in the event that the practice is accredited with the Health Professions Council of South Africa (HPCSA) as a training facility for students and I consent to treatment by such students or interns.
12. I understand that this consent is subject to the Health Professions Act No. 56 of 1974 (as amended), the Health Professions Council of South Africa (HPCSA), the Mental Healthcare Act, the Social Service Professions Act, the Nursing Act, the Protection of Personal Information Act No. 4 of 2013, the Electronic Communications & Transactions Act no. 25 of 2002, the Children’s Act No. 38 of 2005, the National Credit Act No. 34 of 2005 and that the provisions of legislation will prevail in the case of any conflict with this document.
13. This form shall not in any way be interpreted as derogating from any power or authority or right vested in law to another person, court or statutory body requesting access to such information.
14. I acknowledge that my rights have been explained to me, that I have had an opportunity to discuss the content hereof and ask questions relating to the content hereof, and that I am satisfied to continue, and I provide my consent voluntarily, freely and without duress or undue influence. Where I am a minor, my legal guardian listed hereunder has had an opportunity to discuss the content hereof and ask questions relating to the content hereof, and is satisfied to continue, and provides voluntary consent freely and without duress or undue influence.

By completing the following, I hereby authorise, freely and voluntarily and with knowledge of the implications of such consent, the Practice to disclose the specific information outlined herein to the person(s) mentioned and to the extent identified herein.

Please ask us, at the practice if you, the patient, do not understand any of the clauses below.
1. Fees are set according to the following principles:
1.1. The practice is contracted in with all Medical Aids as far as possible. This means that the fees paid by the funds will differ slightly. Consultations are either long (new patients) or short (follow up), and they are coded accordingly. When a specific therapy is recommended the duration of treatment (nr of sessions) and billing will be discussed beforehand. Sometimes we use 2 or more codes per consultation – this is recommended standard practice and we will explain your bill if you ask. Ultimately, the duration of the consultation determines the codes used. Be assured that your consultation time will be used for your optimal benefit, being aware and sensitive to time efficiency, and that we always bill ethically, bearing in mind the guidelines of the funders (eg PMB billing procedures) More specific information can be obtained from Soula or Benita.
1.2. It remains the patient’s responsibility to familiarise himself with the terms and conditions of the chosen Medical Aid and plan. Ultimately, the amount paid by the Medical Aid will depend on your chosen option (and does not depend on factors such as how well we motivated for the service).
1.3. Our fees cover your Practice visit (i.e. the consultation). We will bill separately for services rendered in the absence of the patient eg. prescriptions, motivations, reports etc.
1.4. Our fees exclude the costs of the hospital (admission, ward, and other fees),
anaesthetists, pathologists (for blood tests), radiologists (for X-rays and scans) and therapists involved
in your care. You have to discuss their fees with them.
1.5. We will gladly assist with chronic medication and PMB applications and explain the outcome of the Medical Aid’s decisions. Ultimately, payment will depend on your chosen option. Note that there will be a fee charged for each motivation.
1.6. Hospital visits / emergencies are also charged as according to the duration of the consultation, but is indicated as “in hospital”
1.7. It is fraud to change a patient’s ICD 10 code in order to get more funding. Please don’t even ask us to
change a code for this purpose.
2. Please note that the cost of healthcare sometimes depends on how your body reacts to treatments. The law allows us to step in to save your life, or to prevent or reduce harm to you. We will charge for the costs of this.
3. All accounts must be settled within 90 calendar days of the date on the account. If you have not received an account from us within 30 days, please let the practice know immediately.
4. By choosing this Practice, you-
4.1. Consent to us submitting the account to your medical scheme. This does not mean that the scheme has received the account or that they accept liability. Please confirm that with them.
4.2. If you do not want any particular account to be submitted to your medical scheme, please let us know before you leave the practice, otherwise the provisions of 4.1. will apply (i.e. we will submit to the scheme)
4.3. Membership (principal member or beneficiary) must be valid at the date of healthcare delivery.
5. You, if you are an adult, remain personally and fully liable to settle the full account, irrespective of whether your scheme gave pre-authorization, pay in full, or not. This also applies if you are a dependent on someone else’s medical scheme.
6. If your account is not paid after the 90 calendar days, we will give, in terms of the National Credit Act, notice of 20 working days and if you fail to settle the account within 10 days, we will undertake debt collection
processes. This may result in you having a bad credit record. We will charge the maximum amount of 2% interest per month on all outstanding accounts. You will be responsible for all costs relating to the debt collecting.
7. If you feel that your medical scheme should have paid in full, you can lay a complaint at the Council for Medical Schemes by fax: (012) 431-0608 or at this email address:
8. New patients must complete the required documentation before the appointment is confirmed ie. If we do not receive the signed form from you in time we might have to book another patient in your timeslot.
9. Appointments not attended and not cancelled before 10am on the day before your scheduled appointment will be billed for (to be paid by the patient; this is not sent to the Medical Aid).
10. If an appointment is not confirmed, it may be used for an emergency patient.
11. A yearly administration fee of R300-00 per patient is payable if the practice is not contracted in by the patient’s Medical Aid.
12. The practice will only provide sick certificates should the specific condition warrant such a certificate. If a diagnosis is provided on the sick certificate, the certificate will be handed only to you, unless otherwise specified by you in writing. Discretion in disclosing your condition or diagnosis to your employer/ a third party, remains with you.
13. Although we will do our best to render the services at the time we set, sometimes we may attend to an emergency and run slightly behind.
14. We do accept communication by email, whatsapp and sms but is NOT a substitute for a face-to-face consultation. ie. We will sometimes recommend a consultation in the office. We may charge you for services rendered via sms or electronic media per billing policy. Patients should give written consent that the doctor may engage with the family via electronic media. Please complete our Consent to Disclosure form (4).
15. This Practice also offers Skype, Zoom and telephonic consultations in special cases. We post prescriptions via Postnet if the prescription cannot be collected or email them to a pharmacy on your request. The postage fee will be added to your bill. Please complete our Telehealth Consent (5) form (specific for the lockdown period from March 2020).
16. The Practice aims to ensure that all complaints and concerns are addressed appropriately and expeditiously. When something is a concern or problematic, use the practice’s complaints form. The practice urges all persons to use this avenue before taking any action at any external entity. Please complete our Compliments and Complaints form (6).
17. This document constitutes a contractual agreement by the practice to protect all personal information in confidence.
18. We will use your information only in relation to your healthcare In general, we keep all your information confidential, also when you are a child over the age of
19. We can only release information with your written consent, even if a family member requests the information. Please complete our Consent to Disclosure form (4).
20. The law compels us to disclose your personal information and by agreeing to our services, you acknowledge this legal duty that we have to disclose:
20.1. To your medical scheme: a diagnostic code and details of the treatment and/or operation, so that the scheme can evaluate whether it falls within your benefits.
20.2. The Compensation Commission / Road Accident Fund: they require full claims information.
20.3. To referring and other healthcare professionals: Information that is necessary and in your best interest will be shared with such healthcare professionals in terms of the National Health Act.
21. Some medical schemes provide all information on all the dependents on a scheme to the principal (main) member. We are not liable for any personal information disclosed as a result of the scheme’s practices.
22. You confirm that you understand that in healthcare results cannot be guaranteed. Results also depend on how one’s body reacts to the treatment.
23. You confirm that you understand that your own behaviour or that of a child or dependent may affect the outcome of the healthcare received. You agree to follow the instructions provided to you by the healthcare professionals and/or come for follow-ups, etc. If you do not do this, you undertake to not hold the Practice and its staff liable for any negative consequence.
24. You confirm that you understand that, as a parent or legal guardian, you are legally liable to cover the cost of your child’s healthcare, even if the Children’s Act allows the child to provide consent to treatment
25. We will obtain your consent for substitutions and explain how generic medication may be used. If you are offered a substitution at a pharmacy level, ask the pharmacist for information. The law only allows for generic substitution and not therapeutic substitution.
26. Pharmacy- and health legislation prevents us from taking back and refund any medicines or equipment.
27. If there is a proven quality or performance fault with the goods, we will contact the supplier, who will deal with the matter.
28. You must adhere to the rules of the Practice and any instructions given to you by staff or healthcare
29. You have the right to ask questions and to have them answered. If you do not ask any questions, we will assume that you have understood everything and are fine with everything..
30. We understand that life is stressful and that your case is urgent – but BE NICE.
31. You and/or your family or other persons that come to the Practice should not harass the healthcare professionals and staff. They must be treated with respect.
32. We aim to offer excellent service and respond quickly to all enquiries and requests. However, due to our workload, this might take time. Please ask for scripts and make appointments in time to avoid waiting.
33. Please arrange for follow-up appointments in time. It is unethical to write prescriptions without being aware of the patient’s current clinical presentation, and we will sometimes say no for your safety.
By signing this I declare that I have read the Practice's terms and conditions above and that I have understood the information therein. I also understand my personal data is collected & agree to receive emails and SMS's from this practice. I also give consent that patient information will not be destroyed.*
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