Consent form

Consent Form

Consent to Capture your Health Records Electronically, Receive Telehealth Services and to Share and Disclose your Health Information to yourself and associated health care providers. (Children 12 years or older, Adults 18 years of age and older and of sound mind)

Please fill in your details below:

Agreement

This agreement is between the undersigned patient and collectively and separately Dr M R Hira Practice INC , Dr P Hira INC and associated doctors and clinical associates employed at these practices.

Consent for the use of Electronic Health Records.

I, hereby agree:

To allow the doctors and clinical associates at these practices to capture and retain my Health Records Electronically in a password protected secure and encrypted form which includes, the doctors E-notes, voice recordings, images, test results and reports relating to my health captured during and or related to my consultation.
To have my Health Records shared electronically to either myself or exclusively to other health practitioners and specialists that the practice engages with as and when required for an opinion to allow for better management of my health condition and understand that should such data be breached, I cannot hold the practitioners responsible.

Consent for the use of Telehealth Services

I, hereby agree:

That irrespective of being a new patient or having an established practitioner-patient relationship, that I may choose to receive Telehealth Services from the clinical associates and doctors associated to these practices by means of electronic media (Skype, Zoom or similar; and/or by telephone and/or by WhatsApp Call or FaceTime call and/or Email and/or SMS), which I believe to be appropriate for the problem I have when choosing to consult in this way.
That the Practitioner may encourage me to present myself for a face-to-face consultation at a healthcare facility close to me, if he/she is in doubt that the telehealth consultation is in my best interest.
That I will be billed for a consultation at the rate the medical scheme pays for such consultations or be billed privately if uninsured.
That, although the Practitioner will adhere to the existing rules relating to confidentiality, I understand that I must take the necessary precautions at home to ensure my confidentiality during the telehealth service provision.

Signed:

Name:
Date:
Address:	Number Street City State Postal code Country
Consent Given:	Please tick the box → →

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