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

This consent can also be obtained verbally during a telehealth consultation or contact (a record of which verbal consent must be kept), or by electronic means, e.g. by email, whatsapp, etc., a copy of which must be saved

Your content goes here. Edit or remove this text inline or in the module Content settings. You can also style every aspect of this content in the module Design settings and even apply custom CSS to this text in the module Advanced settings.

Kindly complete and submit the form below. All fields marked with * are mandatory

Name and Surname
Patient full names and surname
Field is required!
ID Number
Patient ID number
Field is required!
Medical Scheme
Patient medical scheme name and number
Field is required!

Agreement to Telehealth Services

I, the Patient, hereby agree:

  1. To receive a psychiatric service from the Psychiatrist of this Practice, by means of electronic media (either Telephone Call, Cell phone Call, Skype, Zoom or similar electronic communication; Whatsapp Call or Video Call or FaceTime call or whichever electronic media is available and convenient to both parties which is closed for only this interaction (public social media not allowed)), in terms of the Disaster Management Act, the Health Professions Council of South Africa (HPCSA) and the Council for Medical Schemes (CMS) for the period of the Covid-19 Lockdown.

  2. There is no subscription required when using the electronic platforms mentioned above, such as costs for the Applications (“Apps”) used, but I understand that I will carry my own costs of any infrastructure and/or running costs associated with such service being rendered e.g. the data used, the telephone and/or computer, etc.

  3. That this platform will be used to render healthcare services to me, and that the usual consent processes (required from me in writing) will be followed (i.e. I will be informed of my health status, as well as the benefits, risks and implications of the care). I understand that I can opt out of receiving care, at any stage, but acknowledge that it may not be in my best interest and I therefore release the Psychiatrist from legal liability for this.

  4. That I have to disclose all health information to my Psychiatrist, such as other health conditions or ailments I have, and all medicines I am taking (including supplements and any “natural” remedies). I understand that these aspects influence the treatment and care options.

  5. That I have to make an appointment prior to each contact where Telehealth will be provided.

  6. That I will be billed for a Telehealth consultation or psychotherapy session at the usual rate that would have applied for a face-toface interaction or any part thereof. I acknowledge that I am aware that I can contact the practice to ascertain the specific tarrif applicable to me, which is determined by the service rendered and my status as either a patient with or without membership to a medical scheme.

  7. I also understand that, due to the nature of the profession, the Psychiatrist may have to give urgent attention to other patients, and/or have to move my appointment to a later or earlier time or day.

  8. That my medical scheme may or may not cover the costs of this care.

  9. That I understand the Psychiatrist is by law obliged to take notes during the Telehealth session. The session will not be recorded as a video or audio file by both parties, unless specific consent has been granted by both parties in writing. The psychiatrist will devote his/her full attention to the session.

  10. I will be on time for my Telehealth consultation. I understand that this consultation cannot be used to try sort out technical issues.

  11. That the service may have limitations relating to technology, such as data- and internet failures (e.g. dropped calls or bad reception). I understand that I am responsible for a secure and stable connection as far as possible.

  12. To dress appropriately for the Telehealth interaction, alone and in private in a room that is fully enclosed to ensure an uninterrupted session unless stipulated in terms of section 13.1 below, and with no light source (window, lights or lamps) behind me. I will devote my full attention to the session, and not do anything else, e.g. receive phone calls, answer SMS’s, reply to WhatsApp messages, read emails, cook, care for children or the likes.

  13. That, although the Psychiatrist will adhere to the existing rules relating to confidentiality:
    13.1. I understand that I must take the necessary precautions at home to ensure my confidentiality during telehealth service provision, and, where I wish for another person to be present during the Telehealth engagement, I will forward a written and signed consent for that person’s presence, clearly indicating the person’s details, the date(s) and time(s) of the consultation(s);
    13.2. I understand that, and agree that, should the Psychiatrist believe that I may have been exposed to Covid-19 and/or do have Covid-19, s/he would refer me for tests, and I understand that the results of such tests must be reported, by law, to the NICD – National Institute of Communicable Diseases.

  14. That if issued with a prescription, such a prescription will be provided electronically to my pharmacy of choice, and a copy will be provided to me by the pharmacy when I pick up the medicine or when it is delivered. I understand the requirements placed on me by the Regulations regarding travel and movement during the Covid-19 Lockdown period.


 

I, therefore, freely and voluntarily consent to this service, and I understand the implications thereof, including the costs related to it.
Place
Field is required!
Select a date
Field is required!
Patient Signature
Which the Practice and Patient agree can be electronically affixed, constituting the valid signature and therefore consent of the above patient.
Field is required!