INFORMED CONSENT AND TERMS AND CONDITIONS

This agreement is made of two parts. Number 1 – Informed consent Number 2 – Terms and Conditions of your treatment By fixing your signature electronically on the patient intake form you confirm that you have understood and agreed to these terms and conditions and that you have been presented with the opportunity to ask any additional questions with the practitioner.

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 and history, which may be pertinent to my consultation and treatment 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 I have an obligation to inform Dr. Debbie Smith if any of the proposed treatments and/or methods would in any way infringe on any psychological and or religious believe that you have.

1.3. 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.

1.3.1 I specially confirm that any risks and side effects have been discussed with me in relation to acupuncture treatment and that I fully understand them.

1.3.2 I specially confirm that any risks and side effects have been discussed with me in relation to Chinese medicine treatment and that I fully understand them.

1.3.3 I specially confirm that any risks and side effects have been discussed with me in relation to Homeopathy treatment and that I fully understand them.

1.3.4 I specially acknowledge that I have an obligation to inform Dr. Debbie Smith of any allergies I may have which may impact my treatment.

1.4. 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. I further understand that I have the opportunity to obtain a second opinion.

1.5. 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 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. By signing this form you confirm that the practitioner has explained all of the above in detail to me and that the practitioner has adequately, and to my satisfaction, provided me with all the information I require to make an informed decision in relation to my treatment. I further acknowledge that the aforementioned is not a closed list and there may be additional risks and/or benefits.

1.6. Dr. Debbie Smith further provides telemedicine treatment. Telemedicine is the practice of medicine using electronic communications technologies to conduct consultations. You make use of these services entirely at your own risk. Dr. Debbie Smith makes no representation or warranty whether express or implied that the virtual platforms used to conduct these services are free from interruptions, viruses, spyware or other technological disruptions. In the event that you are suffering from a serious health condition you must consult a healthcare professional immediately. These sessions may also be recorded and you are to inform Dr. Debbie Smith of any objections you may have in relation to the recording of the session. “With this knowledge, I voluntarily consent to the above procedures”

TERMS AND CONDITIONS PRIVACY

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 accordant with paragraph 2.1 above, I hereby provide written authorization 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.

 2.3 I am further aware that the disclosure of my information and the protection thereof is further governed by the Protection of Personal Information Act which further prescribes how my information must be obtained, processed, stored and disclosed.

2.4 I am further informed that Dr. Debbie Smith works with other healthcare practitioners within the same practice or building which practitioners and practice staff will have access to my personal information and medical practice file and by signing this agreement, I confirm not having any objection thereto.

PAYMENT OF FEES

3.1 I acknowledge that notwithstanding any membership or any medical scheme, I am personally responsible for the payment of any and all amounts by 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 needs 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 that any amount to Dr Debbie Smith, I shall be responsible for that amount 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 explained to me, 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 own client scale), tracing fees and other related costs associated therewith.

3.5 Missed or cancelled appointments not notified to the practice before 24 hours of the commencement of the consultation will be invoiced in full to which I fully agree by affixing my signature hereto.

DISCLAIMER & TELEMEDICINE

4.1 I confirm that the advice of Dr Debbie Smith makes no claim to cure or treat any specific medical condition nor that the treatment will have the desired results.

4.2 I herewith confirm that my participation in this treatment is voluntary and that I am fully aware of all the benefits, side-effects and risks associated with the treatment and as such I hold Dr. Debbie and the practice harmless against any loss, injury and/or liability whatsoever which may occur due to the treatment.

4.3 By agreeing to have a telemedicine consultation, you acknowledge that you have reviewed these benefits, risks, and alternatives, and you agree that you consent to a telemedicine consultation. You have the right to withdraw your consent at any time by ending this telemedicine consultation session.

WARRANTY

5.1 I hereby warrant that prior to beginning any health program that I will consult with my treating practitioner, and where necessary, ensure that he or she is informed at all times and share any concerns conveyed to me with Dr. Debbie.

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 and that I will remain the responsible party for the payment of the account.

GENERAL

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 event of telemedicine, please ensure you are logged on to the agreed platform 10 minutes prior to the scheduled start of the session. In the case that you are late, your treatment will be shortened so that we may keep on schedule for our subsequent patients.

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 Returned Medication: According to the Medical Control Council no medications are returnable under no circumstances. By accepting you are paying for the medication you agree and accept the prescription and medication.

6.4 You further confirm of being aware that you may refuse any medical treatment and/or withdraw your consent to such treatment and services at any time.

6.5 This consent may be reviewed every 6 months or at any time that Dr. Debbie Smith deems it to be necessary or required. By signing this document, you legally bind yourself to the terms and conditions contained herein albeit electronically or physically. Thank you for your understanding and cooperation.

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Please click on the link below to view the Fees for Consultations and Services provided