I agree to this agreement and terms and conditions.
This agreement is made of two parts.
Number 1 – Informed consent
Number 2 – Terms and Conditions of your treatment
1. INFORMED CONSENT
1.1. I the undersigned acknowledge and understand that I have a legal duty to fully inform Dr Debbie Smith of any and all relevant medical information, which may be pertinent to my consultation with her. This shall include (but not be limited to) information pertaining to any diagnosis, current treatment, or medical condition of which I am aware, or am currently receiving treatment or care for by a registered health care professional. 1.2. I confirm that the purpose and nature of therapy and or advice, together with the benefits, risks, if any, associated with such advice have been fully explained to me, and that I have been afforded the opportunity to ask any questions pertaining to such. 1.3. I further confirm that I am responsible for the manner in which I utilise the information given to me, and that where necessary I shall consult with my treating health care professional as and when advised to do so. 1.4. Acupuncture consent. Acupuncture means the stimulation of certain points near the surface of the body by the insertion of special needles. The purpose of acupuncture is to prevent or modify the perception of pain and is thus a form of pain control. In addition, through the normalisation of physiological functions, it may also serve in the treatment of certain diseases or dysfunctions of the body. Acupuncture includes the treatment methods of electro acupuncture, mechanical stimulation, moxibustion and gua sha. The potential risks: slight pain or discomfort at the site of the needle insertion, infection, bruising, weakness, fainting, nausea and aggravation of problematic systems existing prior to acupuncture treatment. The potential benefits: Acupuncture may allow for the painless relief of one’s symptoms without the need for drugs, and improve balance of the body leading to prevention of illness, or the elimination of the presenting problem. “With this knowledge, I voluntarily consent to the above procedures”.
2. TERMS AND CONDITIONS
2.1. I understand that in accordance with section 14 of the National Health Act, 2003, I have the right to medical privacy and confidentiality, and that such information may not be disclosed to any party without my written authorisation. 2.2. In accordance with paragraph 2.1 above, I hereby provide written authorisation to Dr Debbie Smith to disclose any information to my treating health care practitioner, medical scheme or insurer (where applicable), which shall include any information pertaining to my consultation, nutritional advice and related matters.
3. PAYMENT OF FEES
3.1. I acknowledge that notwithstanding any membership of any medical scheme, I am personally responsible for the payment of any and all amounts due to Dr Debbie Smith for her services rendered. This is a cash practice. All consultations and medications need to be settled in full after each consultation. Repeat medications need to be settled in full at time of collection and dispensing them. Any special medication that is prepared or ordered at the time of preparing the medication or ordering them will be for my account. Furthermore, in the event that I claim from my medical scheme or insurer, and for whatever reason either fails to pay, or pays only in part, I shall be responsible for any amount still owing to Dr Debbie Smith or part thereof, in my personal capacity. 3.2. I understand that it is my sole responsibility to submit claims to my medical scheme or insurer, and that Dr Debbie assumes no responsibility in this regard. 3.3. I confirm that I have had all the costs associated with Dr Debbie Smith’s services noted as part of this document, and that I have agreed to those charges. 3.4. In the event that I fail to pay any amount to Dr Debbie Smith, and costs are incurred in the recovery thereof, I shall be liable for those costs, including (but not limited to) any legal fees (at attorney and client scale), tracing fees and other related costs associated therewith. 3.5. Missed or cancelled appointments not notified to the practice 24 hours in advance will be invoiced in full. 4. DISCLAIMER 4.1. I confirm that Dr Debbie Smith makes no claim to cure or treat any specific medical condition by the advice or treatment she provides.
5.1. I hereby warrant that prior to beginning any health program I will consult with my treating practitioner, and where necessary, ensure that he or she is informed at all times. 5.2. In the event that I sign this Agreement on behalf of any minor, I warrant that I am authorised to act on his or her behalf, and that I am legally entitled to make informed decisions pertaining to his or her health.
6.1. Appointment times: In order to fully benefit from your treatment, please arrive at least a few minutes prior to your appointment time. In the case that you are late, your treatment will be shortened so that we may keep on schedule for our subsequent patient. 6.2. Blood test results: Where appropriate Dr Smith will email or SMS results if interpreted to be normal. Out of range pathology and all specialised Functional Medicine tests including DNA reports will require a follow up appointment to be scheduled. 6.3. Medicines or supplements specially compounded or specially ordered for a patient will require payment to be made before such items are compounded or ordered by the practice. These items are not refundable regardless of whether they have been collected by the patient. 6.4. Dispensed medicines may not be returned. according to the MCC (Medical Control Council regulations).
By signing this document you legally bind yourself to the terms and conditions contained herein. Thank you for your understanding and cooperation.
Billing policy of Point of Origin / Dr Debbie Smith / Dr Sandra Squara
- This practice charges the fees it regards as appropriate in terms of the experience, services and training of the professionals working in the practice, as well as the cost- base of the practice. Competition law dictates that practices may not agree to charge the same or similar fees.
- Fees increase on an annual basis and patients will be notified of this.
- The practice will provide patients with a price of goods and/or services, and where it is unable to do so, it will provide a cost estimate to the patient. It should be noted that healthcare is not an exact numerical science, and the duration of services, or the number of items used cannot always be exactly estimated. In some cases the amount of medicine needed are calculated on the specific patient’s needs and factors such as, for example, weight.
- In many cases other health facilities, such as hospitals, theatre’s, clinics, other doctors (such as anaesthetists, pathologists, etc.), or other healthcare professionals (occupational therapists, physiotherapists, etc.) will be involved in the patient’s healthcare. Such facilities and professionals will charge their own fees in addition to the fees of this practice if they also render healthcare services to you.
- Note that unless we have agreed fees with your medical scheme, the fees that we charge and the benefits awarded by your scheme may not overlap. This would mean that you may be required to pay the difference, or in some cases, depending on the patient’s medical scheme, pay for the treatment in full. Should you feel aggrieved by the decisions of your medical scheme, you can approach the:
Council for Medical Schemes at: firstname.lastname@example.org or fax (012) 431- 0608. Note that the CMS would want patients to exhaust internal remedies (appeals in the scheme) first.
- Also note that your medical scheme may require pre-authorisation and/or a motivation prior to certain treatments. Pre-authorisation or scheme approval is, according to schemes, no guarantee of payment.
- Should you (the patient, if you are an adult, or the parent or guardian of a child-patient) not pay your account within 10 calendar days, we will give you notice of 20 business days whereafter we will refer your account to [an attorney / a debt collecting agency]. This will attract additional collection- and other fees. We reserve the right to charge interest of 10% per month on overdue accounts.
- Please ensure that we always have your latest contact details to prevent you from missing any important communication from us. We may contact the person(s) indicated on your personal information form if we cannot get hold of you and your account remains unpaid.
- Patients are encouraged to approach us early on if they experience problems with the payment of the account.
- In deserving cases, we may reduce our fees to accommodate such patients. This practice also participates in various charitable activities.
Dr. Debbie Smith , Homeopath recognize the importance of protecting the privacy of your personal and medical information. During a visit to our practice your privacy is respected. As well as all details given via any medium/platform to us.
We do not collect personal information about you unless you voluntarily choose to provide it to us. This would be the case if you provide us with your information for the purpose of registering you as a patient, providing a payment, or sending us an e-mail, in which you voluntarily provide your name, contact information and medical history. Our staff requires certain information to contact your medical aids or respond to queries. We do not use this information for any other purpose. We protect all personal information in our custody with strong security safeguards, including strict access controls.
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Please click on the link below to view the Fees for Consultations and Services provided