By clicking consent, I agree to the following:

TERMS AND CONDITIONS

PRACTICE:

1. The Practice means the medical practice as described by the Health Professional Council of South Africa.

ACCEPTANCE:

2. The undersigned, patient, responsible person, parent, legal guardian, or surety of the patient, hereby assumes liability as the principal debtor, alternatively as co- debtor jointly and severally with the patient, for the payment of any claims by the Practice arising from medication given or services rendered to the patient, or to be rendered to the patient, notwithstanding the existence of a medical aid fund or insurance covering such claims.

TERMS OF PAYMENT

3. Any person who signs this document in any of the capacities described above, confirms that (1) he is appraised of the tariffs charged by the Practice (2) he will settle the account within 30 days after receipt (3) he will notify the Practice within 14 days after the treatment date if he has not received an account and (4) the Practice is not liable for the submission of medical claims with any medical fund.

BREACH:

4. In the event where any of the abovementioned parties commits a breach of contract, the Practice is entitled to take immediate legal action and charge arrears interest at a rate of 24% per year on the outstanding balance from the date of invoice to the date of

GENERAL:

5. This Form of Admission constitutes the whole and entire agreement between the parties and there have not been and there are no agreements, representations or warranties between the parties other than those specifically set forth herein. No variation, modification or cancellation of this agreement shall be of any legal force or effect unless the same shall be confirmed in writing and signed by all parties

SERIES OF APPOINTMENTS

6. In the event where the patient books a series of appointments for consultation, each appointment shall be regarded as a cause of action and the Practice will be entitled claim full consultation fee if the consultation was not cancelled 24 hours in Terms of clause 2 above will apply to the account. Please cancel 24 hours in advance if you are not able to keep an appointment. A full consultation fee will be charged for appointments not kept or cancelled within time.

PERSONAL INFORMATION:

7. The undersigned, patient, responsible person, legal guardian, or surety of the patient, hereby authorises the Practice to collect, share and exchange credit information concerning them with any credit bureau or any other person or corporation with whom they may have had or may have financial dealings, as well as, where applicable, other information requested pursuant to, or in any circumstances contemplated in the National Credit Act, Act 34 of 2005.
8. Furthermore, the Practice is given the right to disclose personal medical information such as ICD10 diagnostic codes and clinical information pertaining to the patient to its legal representatives or debt collectors provided that such information is treated as confidential and in good faith and only insofar as it is necessary for debt collecting purposes.
9. No personal information will be shared to any third party, except with legal representative of debt collectors, in the event of outstanding monies.

DOMICILE

10. The parties choose the domicile at the address shown on the admission form,

LEGAL COSTS

11. Should the Practice commence legal proceedings, the patient undertakes to pay all legal costs relating to the recovery of the outstanding monies in respect of professional services rendered, including attorney fees on an attorney-own-client scale, collection fees and commission, interest and tracing costs.

PROTECTION OF PERSONAL INFORMATION ACT (POPIA):

12. The protection of your personal information and your privacy is of paramount importance to us and we are committed to processing your personal information in full compliance with all current legislation and

13. Part of our commitment to compliance is to inform you of the exact purpose and manner in which your information is being Please contact our Information Officer at info@sportsdietitian.co.za should you at any time believe that your information is not being processed as prescribed by POPIA.

14. We will only collect, hold and process your information in accordance with applicable laws and in accordance with the instructions, requirements or specific directions of the Information Officer. Your personal information will only be used as reasonably expected or authorised by yourself.
15. We will never sell your personal information to anyone and we have taken the appropriate, reasonable, technical and organisational measures to ensure the integrity of your personal information in our possession or under our As such, your personal information is secure and protected against unauthorised or unlawful processing, accidental loss, destruction or damage and unauthorised alteration, disclosure or access.

16. We will never sell your personal information to anyone and we have taken the appropriate, reasonable, technical and organisational measures to ensure the integrity of your personal information in our possession or under our As such, your personal information is secure and protected against unauthorised or unlawful processing, accidental loss, destruction or damage and unauthorised alteration, disclosure or access.

Consent Form

Consent for Nutritional Counselling

 

I, hereby enter into the following agreement with Registered Dietitians Hanlie Jordaan (Pittendrigh) and Anri Kruger hereafter referred to as Sportsdietitian Pty Ltd.

1.       Consent for Nutritional Counselling

• I hereby request and consent to Sportsdietitian Pty Ltd providing Nutrition Counseling to myself or the client for which I am legally
• I understand that the consult will provide information and guidance about my diet, nutrition, DNA and
• I understand that Sportsdietitian Pty Ltd are Registered Dietitians and does not dispense medical advice but will treat a diagnosed medical condition through medical nutrition
• Methods of nutritional evaluation or testing made available to me are not intended to diagnose Rather, these assessments are intended as a guide to enhance my nutritional health.
• Sportsdietitian Pty Ltd will provide nutritional support and nutrition education that relates to existing medical conditions, prevention of chronic diseases, improved athletic performance and, or for general healthy

2.       Confidentiality

• Medical records and personal information and history divulged in the session to Sportsdietitian Pty Ltd will be kept confidential, unless I consent to sharing my medical

3.       Consent for Telehealth / Web-Based Counselling

• Further, when I would like nutritional advice provided through telehealth or web-supported platforms (including but not limited to Zoom, Microsoft teams, Google Meets, Skype, Whatsapp or Telephonic) I understand that these platforms will be used to provide healthcare services to me, and that the usual consent processes are
• I understand that the consultation will be done via video/internet conferencing technology and I agree to
• Practicalities:
  • The telehealth or web-supported consultation is done through a two-way video whereby Sportsdietitian Pty Ltd can see my image on the screen and hear my
  • I may ask questions and seek explanation from Sportsdietitian Pty ltd regarding the methods and processes of telehealth and I may at any time ask that the telehealth consultation be
    • I also acknowledge that if I request for the session to be stopped that it might not be in my best interest and I therefore release Sportsdietitian Pty Ltd from being legally liable for
  • Any paperwork exchanged will be provided through electronic means and I understand that telehealth may have limitations, such as data- and internet failures (e.g. dropped calls or bad reception).
  • The data being used during the online sessions will be my responsibility and at my
• I understand that all available information and all vital information regarding my medical conditions, diet, nutrition, and lifestyle need to be disclosed to Sportsdietitian Pty Ltd, I acknowledge and accept the risks of non-disclosure.
• I understand and consent to the telehealth consultation being

4.       Reimbursement

4.1. I understand that I will be billed for a consultation at the rates indicated in the practice policy and price list. Should my medical scheme not cover the cost of this nutrition consultation, I undertake to cover any shortfall that my scheme does not cover, that may be the full amount. Before the end of the month that the consultation took place in and the dietplan was sent.

I, t­he patient, understand that scheduling a telehealth consultation implies consent. I voluntarily consent to this and I understand the implications thereof.

I agree to all of the above as seen on the Patient Information form.

Medical Consent

In order for me to effectively treat you I would like to outline my basic treatment principles:

I would like to inform you that in terms of the Mental Health Care Act, Act 17 of 2002, the National health Act, 2003 and the Consumer protection Act, 2008 swell as the POPIA act, I need to obtain your informed consent for effective diagnosis and treatment of …………………………… You hereby give me permission to conduct an interview (which may involve us enquiring about your personal history and life), conduct a physical examination (weight, measurements……./ clinical signs  …..), perform the necessary investigations (blood, …….DNA, Sensors……), and prescribe ………………………….treatment (evidence based approach) for your ………………………….

Should you not have the capacity to provide informed consent as a result of your medical condition, I will obtain permission to conduct a thorough history taking, conduct a physical exam, perform blood investigations and prescribe treatment from a legal guardian or family member as is customary in ethical guidelines set out by the HPCSA.

Consent to Treatment: 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), Act No. 4 of 2013. You are therefore requested to provide this practice Sportsdietitian Pty Ltd 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 dietitians at Sportsdietitian Pty Ltd and understand 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 of such withdrawal of consent immediately. Without derogation of the practice record keeping obligations under law, I may obtain a copy of my records taken by the respective health practitioner, or in the event of furtherance of my medical interests, such as consultation with another health practitioner, the original record taken by the health practitioner.
4. I voluntarily consent to provide personal information to the practice including my name, ID number, exact physical address, contact information (email and telephone, sexual orientation, ethnic or social orientation, age, religion, wellbeing, physical and mental health, culture, financial information and medical aid information; all the aforementioned relating to myself as an identifiable living natural person (“Personal Information”), provided that the practice; treats this Personal Information as confidential and that the practice not pass on this Personal Information to third parties except as necessary for medical scheme claim purposes as per paragraph 6 and as per paragraph 9,10 below .
5. I voluntarily consent to the practice disclosing information regarding my medical history, medical condition, suburb/town/city of residence or employ, diagnosis, prognosis, treatment, improvement in diagnosis and recovery, including ICD 10 Codes (“the Medical Information”), to my medical aid, and I understand that such disclosure to my medical aid may result in a breach of my confidential Personal Information. I further understand that my Personal Information as it relates to my health may be processed by medical professionals, health care institutions or facilities or social services which is necessary for my proper treatment and care and or for the administration 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 onto Hubspot patient record management database belonging to Sportsdietitian (Pty) Ltd, which database being hosted online, and that the practice has satisfied itself that all reasonable measures have been taken by Hubspot to ensure that such electronically captured Personal Information and Medical Information remains secure and confidential at all times.
7. I shall provide a full medical history to the practice 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 to arrange for, and or provide, as necessary, additional treatment in the event it is required or deemed to be required.
9. I voluntarily consent that the practice 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 biokineticists, physiotherapists, pharmacists, coaches, physiatrists, psychologists, personal trainers, clubs 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 treatment plan.
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, pharmacy etc; 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.

Confidentiality: Your confidentiality will be maintained at all times with the strictest importance. It may however be necessary to obtain collateral information from past treating physicians and other health care workers. This will be conducted with your consent. Your medical records will at all times be kept confidential.

Prescriptions will be made via Vitagene and your information will be added and shared to the Nordic/ DNAlysis company if you decide to conduct DNA testing; and to a valid pharmacy. The patient acknowledges that the practice is required by law and the medical schemes act to disclose various diagnoses in the form of ICD 10 codes to the relevant medical schemes in terms of claims made. You hereby acknowledge and agree to this disclosure to your medical scheme. If you do not authorize this disclosure it may result in the necessary authorizations for admission and payment for medication and consultations not being paid. It will then be the responsibility of the patient to ensure payment.

Tariffs: This practice is contracted out of medical aid. Payment is strictly on a cash only basis and is payable in advance. Patients are therefore responsible for their accounts. We reserve the right to increase our fees in accordance with the relevant local and ethical guidelines. Alternative arrangements may be made with the practice in advance, should payment be a problem. We reserve the right to obtain outstanding payments, in association with the necessary legal stipulations, as set out. Should your account not be settled immediately, we reserve the right to obtain a third party to collect these fees on our behalf. You will then be responsible for fees incurred in respect of the above. We reserve the right to charge for appointments not cancelled 24 hours in advance. We further reserve the right to charge for telephonic consultation, repeat prescriptions and completion of relevant medical aid and work-related forms Pharmacological and Medical.

Please note that telephonic consultations / Skype/ Zoom/ Google Meets consultations may be charged for according to the stipulated rate. Should you require non-emergency assistance during working hours during the day it is requested that you leave a message with Sportsdietitian Pty Ltd and we will then get back to you at my earliest convenience. Response to electronic correspondence / emails / WhatsApp’s may take at least 72 hours. Should you not receive a response please contact Sportsdietitian Pty Ltd as stipulated above. Nutritional reports and diet interventions that need to be typed will take 7working days to complete. Please be patient as these treatment plans take time to complete.

Termination of Services: Should the therapeutic environment not be conducive to further ongoing care and treatment, the treating company, Sportsdietitian Pty Ltd, reserves the right to terminate treatment and refer you to another practitioner for ongoing evaluation and care; referral letter:

Special Interests: ………………………has a special interest in ………………………………………. , she is a registered sub specialist in …………………… with the HPCSA. The aim is to provide integrated care and improved ……………….., feel that your condition warrants referral then appropriate referral will be conducted.

Patient Obligations: It is up to the patient at all times to provide ongoing updates related to treatment and management, disclose all relevant past medical history and previous attending doctors’ prescriptions. It is the responsibility of the patient to ensure compliance to the treatment programme as set out by your treating dietitian, in collaboration with you.

To request and obtain on my behalf, results and reports from other treating doctors, laboratories, radiology departments and any other entity which may have information relevant to my diagnosis, treatment and management; and understand that this consent is valid until revoked in writing.

I understand that as a patient I can withdraw this consent at any time bearing in mind that withdrawal may not be possible in certain instances without negatively affecting patients’ rights and contractual relationships, for which patient takes full liability and indemnifies the Practice.

I acknowledge that I have received information about all the consultations available and estimated costs thereof.

The practice is not a designated service provider (DSP) of any medical insurance company and therefore prescribed minimum benefit (PMB) conditions may not be covered in full by my medical insurance (this is determined by the rules of my medical insurer).

I have read, understood and agree to the contents herein. I confirm that I am 12 years of age or older and the particulars and all information furnished by me are in all respects true and complete.