Consent to Treatment 

(adults 18 years of age and older of sound mind) 

By signing the Van Huyssteen and Lennox treatment Consent Form (see link below), I confirms that:

• The Healthcare Professional has spoken to me on how she has evaluated my health. 

• If another Healthcare Practitioner (e.g. doctor) has referred me to the Healthcare Professional, this referral was discussed with me.

• The Healthcare Professional has explained to me the nature and purpose of the planned procedure/assessment.

• I was informed by the Healthcare Professional of what my options of health care are.  I understand these options and have consented to the treatment/treatment plan, described. 

• I understand what this healthcare means and received information from the Healthcare Professional about the duration of treatment, follow-up visits to the Practice as instructed, following self-care and what I must do or not do.

• I have been told about the benefits and any risks associated with the healthcare professional. I understand that there is no certainty that I will achieve those benefits and no guarantee or assurances have been made to me regarding the outcome of this procedure/assessment. I understand the risks, and agree to those risks. 

• I have been informed of the fees charged by the Healthcare Professional, and also that certain fees and costs are excluded from that fee (e.g. hospital and diagnostic tests costs). I also understand that healthcare sometimes requires more than what was anticipated, and the Healthcare Professional will bill for all such healthcare reasonably rendered. If more time is taken to address my healthcare, such extra time will be billed for.

• I have been informed by the Healthcare Professional that confidentiality will always be maintained. I, however, give consent that aspects of the diagnosis/treatment may be discussed with other Healthcare Professionals that are part of the treatment team as needed, in order for the Healthcare Professional to act in my best interest. The Healthcare Professional has informed me that I will at all times be informed of these discussions. 

• I have been told that confidentiality will be limited in the event of me posing harm to myself or a third party, if it will be a public health risk, or if information cannot be contained as confidential according to a court of law or any other relevant legislation (i.e the Children’s Act, 2005).

• I am aware of the following regarding the practice’ POPI Act policy:

• We collect and store the information about you in order for us to adhere to administrative requirements of the practice

• We collect and store information about in or order for us to continually assess, treat and manage your clinical best interest.

• We will use your personal information only for the purposes for which it was collected and agreed with you

• We may disclose your personal information to our service providers who are involved in the delivery of services to you (i.e for billing purposes). We have agreements in place to ensure that they comply with the privacy requirements as required by the Protection of Personal Information Act.

• We will, on an on-going basis, continue to review our security controls and related processes to ensure that your personal information remains secure.

• You have the right to request a copy of the personal information we hold about you.  Please note that any such access request may be subject to a payment of a legally allowable fee

• I was given the opportunity to ask questions regarding the procedure/assessment and these have been answered to my satisfaction and in a language that I do understand.

• I understand that I can refuse healthcare at any stage but also that if I refuse, the Healthcare Professional must explain the consequences of the refusal to me. I will then not hold the Healthcare Professional liable for any of those consequences, should they happen. I understand that if I refuse, I am still responsible to pay for the healthcare I have received up to that point.