Information Form INFORMED CONSENTBy accessing the Treatment and/or signing this Sign-Up Sheet, you: voluntarily opt-in to the Treatment, with full appreciation of the benefits, risks and terms and conditions applicable thereto; acknowledge that you have read, and that you agree to be bound by, the General Terms and Conditions which are provided to you by Shamar Clinic. Unless otherwise defined herein or except where the context requires otherwise, words, terms and definitions used in this form shall have the meaning given to them in the General Terms and Conditions; agree that the General Terms and Conditions constitute compliance with Shamar Clinic's obligations to inform the Client as contemplated in Applicable Law, including in terms of the National Health Act, 61 of 2003 and the Ethical Rules of Conduct for Practitioners Registered under the Health Professions Act, 56 of 1974 ("HPCSA Ethical Rules") in respect of all Treatment rendered by the Practice to the Patient and the Client; and agree that the General Terms and Conditions are binding and enforceable against the Client and Patient. PATIENT'S DETAILSBy providing the information below you consent to this information being kept and processed in accordance with Applicable Law and for the purpose of providing Treatment and for this information to be used to contact you where necessary. You also agree to notify us of any changes and updates to the information provided below.PATIENT NAME AND SURNAME ID NUMBER (OR, IN THE CASE OF NON-SOUTH AFRICAN, DATE OF BIRTH) GENDER CHOICE OF PRONOUN (for example, he/him, she/ her, they/them) REFERRING PROFESSIONAL (if applicable) CURRENT DIAGNOSIS (if applicable) CURRENT MEDICATION RESIDENTIAL PHYSICAL ADDRESS CELLPHONE NUMBER EMAIL ADDRESS SCHOOL GRADE TEACHER'S NAME FEEDBACK AND FINDINGS OF ANY PREVIOUS TREATMENT PROCESSFile Drop files here or Select files Max. file size: 128 MB. PLEASE UPLOAD ALL PREVIOUS PSYCHOTHERAPY AND MEDICAL REPORTS HEREGUARDIANPERSON GIVING INFORMED CONSENT (IF PATIENT IS LEGALLY INCAPABLE OF PROVIDING INFORMED CONSENT) ("GUARDIAN" By providing the information below you consent to this information being kept and processed in accordance with Applicable Law and for the purpose of providing Treatment and for this information to be used to contact you when necessary. You also agree to notify us of any changes and updates to the information provided below.NAME AND SURNAME ID NUMBER (OR, IN THE CASE OF NON-SOUTH AFRICAN, DATE OF BIRTH) GENDER NATURE OF AUTHORITY TO CONSENT (PARENT OR GUARDIAN, SPOUSE, COURT ORDER, ETC) RELATIONSHIP TO PATIENT OCCUPATION PLACE OF EMPLOYMENT WORK PHYSICAL ADDRESS RESIDENTIAL PHYSICAL ADDRESS WORK TELEPHONE NUMBER CELLPHONE NUMBER CELLPHONE NUMBER EMAIL ADDRESS PATIENT'S SPOUSE OR NEXT OF KINPLEASE NOTE THAT THIS SECTION MUST BE COMPLETED EVEN IF YOU INTEND TO CLAIM FROM MEDICAL AID By providing the information below, you confirm that you have obtained consent from the person listed to provide their contact details to be processed by Shamar Clinic as agreed as the person who will be responsible for payment of your account. You also agree to notify us of any changes and updates to the information providedNAME ID NUMBER (OR, IN THE CASE OF NON-SOUTH AFRICAN, DATE OF BIRTH) GENDER OCCUPATION PLACE OF EMPLOYMENT WORK PHYSICAL ADDRESS WORK TELEPHONE NUMBER HOME ADDRESS (if different to patient) CELLPHONE NUMBER EMAIL ADDRESS PERSON RESPONSIBLE FOR PAYMENTBy providing the information below, you confirm that you have obtained consent from the person listed to provide their personal and contact details to be processed by Shamar Clinic as agreed. You also agree to notify us of any changes and updates to the information provided.PERSON RESPONSIBLE FOR PAYMENT (CHOOSE ONE)PATIENTGUARDIANSPOUSEOTHERNAME AND SURNAME ID NUMBER OCCUPATION EMAIL ADDRESS PLACE OF EMPLOYMENT PHYSICAL WORK ADDRESS PHYSICAL RESIDENTIAL ADDRESS WORK TELEPHONE NUMBER HOME TELEPHONE NUMBER CELLPHONE NUMBER MEDICAL AID DETAILSPlease provide your medical aid details should you wish to claim from medical aid. You agree to notify us of any changes and updates to the information providedMEDICAL AID SCHEME AND OPTION MEDICAL AID NUMBER PATIENT’S DEPENDENT CODE MAIN MEMBER OF THE MEDICAL AID MAIN MEMBER’S ID NUMBER SPECIFIC INSTRUCTIONS OR IMPORTANT INFORMATION I, the signatory, hereby agree that all information provided above is truthful and accurate. I further agree that I am responsible for the prompt payment of all Programme fees and that I bear the responsibility to claim back any Programme Fees from my medical aid. Further, in the event that my medical aid does not cover these fees, I agree that this will in no way change my obligation in respect of payment and that I remain responsible for any payment of Programme fees that may be due. I also agree that in the event that my account is handed over to legal representatives or debt collectors, I will be responsible for the Programme fees as well as collection charges and reimbursements. I am aware of my legal rights according to the Protection of Personal Information Act 4 of 2013 and I hereby give informed consent for my personal details and ICD 10 codes to be given to Xero (Shamar Clinic's accounting system), the staff of Shamar Clinic, and all authorised agents of Shamar Clinic. I agree that the account and payment of the account is subject to the Prescribed Rate of Interest Act 55 of 1975 for all accounts and charges that are not paid within a 30 day period. I also agree to the negative listing of my credit information should my account remain outstanding. PATIENT’S SIGNATUREGUARDIAN'S SIGNATUREWHERE THE PATIENT IS NOT LEGALLY CAPABLE OF PROVIDING INFORMED CONSENTDate MM slash DD slash YYYY
