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

1. Consent

By completing the following, I hereby authorise, freely and voluntarily and with knowledge of the implications of such consent, the Practice to disclose the specific information outlined herein to the person(s) mentioned and to the extent identified herein:
Name and Surname
Your Name and Surname
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2. Information

What information is to be disclosed and for what reason?
(see below for possible scenario’s under which disclosure may be necessary or required by the patient)
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3. To whom may the information be disclosed?

Name
Name
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Surname
Surname
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Contact Number
Your Phonenumber
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Person’s relationship to the patient / entity whose information it is
(e.g. my parent/caregiver, my spouse/life partner, my employer, my lawyer, my insurance company, the manufacturer of a product, etc.)
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4. For how long is this consent valid

(Please insert if indefinite or until revoked or if only pertaining to a particular incident (e.g. sick leave taken on specific days or a particular operation or treatment) or for a particular period (e.g. for as long as I am employed by, or from [date] to [date], etc.)
For how long is this consent valid?
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Date
Select a date
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Signature
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Witness initials and surname
Witness initials and surname
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Witness signature
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Patient can give permission and agree that:

 

  • Another person (such as their parent, a spouse, etc.) sit in at the consultation / procedure. Such a person would then hear and/or see information that would otherwise remain confidential between the patient and healthcare practitioner.
  • Another person (such as family members) receive updates on how the patient is doing before, during and/or after a procedure, when in hospital / ICU, etc.
  • Another person or entity can get a copy of specific health records (e.g. a copy of the patient’s file, a medical report, a copy of a sick certificate, etc.), prescription, etc.
  • A person who can consent to treatment and care when the patient cannot (e.g. when the patient is unconscious), can receive information about the patient which will enable them to make the decision.
  • The employer be informed of specific aspects, e.g. the nature of the patient’s illness, how long s/he would be away and why, etc. Patients take sole responsibility for any consequence that may flow from a disclosure to an employer.
  • An insurance company, which require the completion of form, and/or the drafting of a report.
  • A pharmaceutical or medical device company, to which details of a negative event associated with a product must be shared.
  • A medico-legal report, a report constituting a second opinion, a report to an attorney, etc.