Scheduling an Appointment

I, the undersigned, confirm that:

1. I hereby consent thereto that Dr Petrie vd Merwe (and / or duly appointed, qualified and registered representative) to examine myself, family member or legal dependent (unable to consent for themselves). I consent that, after discussion and careful consideration of the risks and benefits of surgery, that Dr Petrie vd Merwe perform surgery on myself, family member or legal dependent

2. That I have the consent of a family member/friend and my employer to disclose their contact details

3. Where I, the patient, am not the Main Member, I have the consent of the Main Member to disclose his/her details for account administration

4. That the patient (dependent) or main member is primarily responsible for payments of accounts for services rendered

5. Medical schemes differ regarding benefits for services rendered, and that it is the responsibility of the patient or main member to contact the medical scheme prior to appointment/admission to confirm any specific stipulations

6. I also accept liability for professional fees that may result from consultation, consumables, and treatment

7. I acknowledge that authorisation from my medical scheme is not a payment guarantee and accounts need to be settled within 30-days of service rendering

8. Should any legal action be required to recover outstanding fees, the legal fees at attorney-client scale will be for my account

9. Interest will be charged on accounts that are in arrears for 30-days or more. Interest rates on outstanding accounts are based on HPCSA regulations

10. Appointments must be cancelled within 24 hours and failing to do so will result in the full consultation fee being charged

11. The accompanying “Patient Information Document” (provided to you separately) has been read and that you as the patient is bound to the content thereof and that you have had an opportunity to ask questions on aspects thereof that you were not certain about

12. You are aware of your rights under the POPI Act, including your right to refuse to consent to marketing and to refuse disclosures - unless required by a law, and to change or remove information, where possible

13. The Account Holder, surety or legal guardian hereby consents to the disclosure and exchange of personal financial information to a credit bureau or financial institution in accordance with the National Credit Act

Information about you cannot be exchanged without your consent. Your signature on this release authorises This Practice to obtain and release personal information regarding your care in accordance with PAIA and POPIA Compliance. Personal & Special Personal Information is collected, stored & shared by This Practice for the following reasons (for a more comprehensive description of all records held at The Practice as well as policies implemented by The Practice, please contact The Practice Information Officer for a copy of the PAIA Manual as well as the POPIA Compliance Manual.

PURPOSE: For the holistic treatment of you as the patient; For the administration of your patient treatment and the practice; For the performance of duties in terms of any agreement between yourself and the practice; Administrate your accounts and manage any application, agreement, or correspondence that you may have with The Practice; Any other reasonably required purpose relating to The Practice.

Please note, that this practice is administrated by MFI (operator) and as a result, the following information is disclosed for administrative purposes: Client/patient contact and medical aid details, ICD-10 codes, correspondence and Consultation dates and procedures.