Consent to Treatment 

(minors) 

Informed consent for children under the age of 12 must be signed by the relative parent and/or guardian. 

Children above the age of 12 who show an understanding of the below discussion and comprehend the nature and scope of it, have to sign the informed consent form themselves, unless otherwise required by relevant legislation (i.e. surgical intervention where a guardian needs to co-sign).

By signing the Van Huyssteen and Lennox treatment consent form, I confirm 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 other risks associated with the health care. I understand the risks, and agree to those risks:

• I understand that I can refuse healthcare at any stage, but also understand 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. If I refuse, my parent(s)/guardian/caregiver must still pay for the healthcare I have had up to that point.

• I understand that it will be the responsibility of my parent(s)/guardian/caregiver to pay for my healthcare. I understand that there are medical schemes and that accounts may to these schemes for them to pay it. I have also been informed that my account to a medical scheme will show that I have visited this Practice. 

• I have been informed by the Healthcare Professional that confidentiality will always be maintained. This means that the Practice will not share information on my healthcare with anyone without asking me if this would be ok and me signing a form to give such consent.  

• I understand that in some instances it would be better for my parent(s)/guardian/caregiver to be informed of the healthcare received by me, but that it is still my choice as to whether I would want them to know or not.  

• I have also been informed by the Healthcare Professional that they may in cases of emergency step in to save my life. They may also when it is not an emergency, approach the Minister of Social Development and/or Courts to make a decision on whether I should receive treatment or not.

• I have informed my Dietitian of my allergies and medication.

• 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.