I hereby request and consent to the performance of chiropractic treatment (or on the patient named below, for whom I am legally responsible) by the chiropractor and/or anyone registered as a chiropractor working in this office authorized by same. I further understand that such chiropractic services may be performed by the chiropractor and/or registered practitioner of chiropractic who may treat me now or in the future at this office.
I am further aware and consent that in order to proceed with an effective treatment, my health status must be evaluated by means of an interview and/or the performance of clinical tests. The reason for this is to diagnose my condition but also to determine any contraindication I may have to any recommended treatment. I am further aware of my right to have a person of my choosing present during certain physical examinations and my right not to remain disrobed any longer than is required for accomplishing the examination.
I understand that, as with any health procedure, there are certain risks that may arise during chiropractic treatment. The risks associated with joint manipulation and mobilization are typically minor if they occur, possible side effects include mild to moderate discomfort, autonomic phenomena such as dizziness, headaches and post treatment discomfort. More severe complications are extremely rare but have been reported, such as fractures, dislocations, disc herniation or progression of neurological symptoms and stroke. Other chiropractic treatments that this practice may utilize are dry needling therapy, electrotherapy, temperature therapy, soft tissue therapy, strapping and bracing. Risks associated with these therapies include bleeding, bruising, infection, lung puncture, pain, autonomic phenomenon such as dizziness and nausea, burns, electrocution, skin irritation and discomfort.
Should I experience any side effects, I confirm that I will immediately notify my chiropractor and inform him of same. My failure to raise any concern will create the assumption that I am satisfied with the service provided and further indicates that I am not experiencing any side effects to the treatment provided.
I acknowledge that I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, the treatment options and recommendations for my condition, costs and the contents of this consent. I also understand that results are not guaranteed.
I intend for this consent to apply to my present treatments and, in future, should it occur that my condition changes during the course of my treatment, I will participate in any decision affecting my personal health and course of treatment. I further note my right to withdraw my consent at any time for any specific procedure and/or treatment.
I understand my chiropractor’s legal duty and herewith consent to the disclosure of my diagnosis to the medical schemes, other medical professionals and support staff in the employ of this practice for purposes of reimbursement and/or settlement of my account, administrative tasks and/or referral. I also hereby accept full financial responsibility for this account until it is settled in full. I confirm that all details provided are both true and correct. It has further been explained to me the costs involved in chiropractic treatment and agree to said costs. I also understand that should I not cancel an appointment within twenty four (24) hours of said appointment I may be invoiced for the full amount.
I further understand that access to the premises of the chiropractor and the use of all facilities is done at my own risk. Neither the owner of the premises nor the chiropractor who operates the business or their employees, agents or anyone temporarily in their service shall be liable for any damage, loss and/or injuries sustained as a result of such entry unto the premises and I hereby indemnify the owner of the premises, the chiropractor/s and all employees in their service, agents and/or temporary workers against any liability for loss or damage of any kind whatsoever.
Any video recordings or photography of treatments/manipulations are prohibited unless expressly permitted by the Chiropractor and for private use only. Such recordings and videography may under no circumstances be shared or distributed in any way or form on any public platform, be it social media or WhatsApp group or any other public domain or area where more than one person will have access to such video or photograph. Any such actions will be in contravention of the rules of the AHPCSA and will breach practitioner and patient confidentiality.
INFORMED CONSENT TO THE RELEASE OF PERSONAL AND MEDICAL INFORMATION
I understand my chiropractor’s legal duty and herewith consent to the disclosure of my diagnosis (ICD-10 codes) to the medical schemes for purposes of reimbursement and/or settlement of my account. I further understand that this disclosure has consequences and same has been explained to me.
I acknowledge that once my information has been sent to the relevant medical scheme, Dr Jacques H Maree Chiropractor has no further control over the management and utilisation of the information and understand that the medical scheme will take responsibility for any further disclosure or utilization of such information for whatever purpose.
I further understand and consent to the disclosure of my medical information to other chiropractors and support staff in the employ of Dr Jacques H Maree Chiropractor. It has been explained to me that each member of the staff has signed a confidentiality agreement which ensures that they are not able to disclose my personal and medical information to any third party, family member etc. of the respective employee.
Dr Jacques H Maree Chiropractor will not disclose any personal and medical information to any of my friends or family members unless express consent is given by me, authorising them to disclose certain information to same.
I have the right to withhold my consent to the disclosure of my personal and medical information and understand that same will result in me having to reimburse and settle the account directly with Dr Jacques H Maree Chiropractor.
I intend for this consent to apply to my present treatment and, in future, should it occur that my condition changes during the course of my treatment, I will sign a new informed consent form to give effect to said decision.
I indemnify Dr Jacques H Maree Chiropractor from any liability, damages or whatsoever that I may suffer as a result of this disclosure and that I will hold this practice and its staff harmless of any further disclosures and prejudice I may suffer as a result of such disclosures.
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INFORMED CONSENT TO THE FINANCIAL RESPONSIBILITY OF MY ACCOUNT
I, hereby accept full financial responsibility for this account until it is settled in full. I confirm that all details provided are both true and correct. It has further been explained to me the costs involved in chiropractic treatment and agree to said costs.
I understand that should I not cancel an appointment within twenty four (24) hours of said appointment I will be invoiced for the full amount.
Accounts will be rendered electronically and it is my duty to ensure that all information is correct. Should information be incorrect I will ensure that I notify Dr Jacques H Maree Chiropractor within a reasonable time. I further am responsible to rectify/clarify and mistakes/errors made by the medical aid with the medical aid directly, Dr Jacques H Maree Chiropractor will not be liable/responsible for said mistakes/errors.
In the event of an injury on duty, it is my responsibility to submit the necessary documentation within ten (10) days after the starting date of the treatment. Should I fail to submit same, I will become liable for the full amount.
Should I not effect payment of any outstanding invoice, Dr Jacques H Maree Chiropractor will proceed as follows:
1. A follow up telephone call, sms or e-mail will be sent should the account not be paid within thirty (30) days;
2. A final written warning will be sent via e-mail to my personal e-mail address should the account not be paid within sixty (60) days;
3. Should I not settle the invoice after receipt of the final written warning, the account will be handed over to attorneys for further legal action;
4. I acknowledge that as a result of my failure to pay the account, I will be liable for all legal fees, on an attorney client scale, incurred in the collection of the outstanding account.
I herewith confirm the aforementioned and further that all costs implications have been discussed with me.
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WITHDRAWAL OF CONSENT
I understand that it is my right to withdraw consent or refuse care at any time or for any specific procedure. I further confirm that in doing so there are, or might be, implications, risks and obligations for my health. The chiropractor has explained such implications, risks and obligations to me.
I have considered these implications, risks and obligations, and herewith confirm my withdrawal of consent for the following procedure or evaluation: ___________________________________________________________
