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Please fill in and digitally sign the concent form below
I, the Patient, hereby agree
1. To be serviced by the Practitioner from this Practice [if applicable: for a series
of ........................... number of appointments, with whom I have an established practitionerpatient relationship
or: Where I am a new patient and such itelehealth will be in my best interest by means of
electronic media (Google Meet) as authorized by the Health Professions Council of South
Africa (HPCSA) for the period of the Covid-19 Lockdown or longer if extended.
2. I understand that this platform will be used to render healthcare services to me, and that the
usual consent processes will be followed (i.e. I will be informed of my health status, as well
as the benefits, risks and implications of the care). I understand that I can opt out of
receiving care at any stage, but acknowledge that it may not be in my best interest and I
therefore release the Practitioner from legal liable for such an opt-out.
3. There is no subscription required when using the electronic platforms mentioned above,
such as costs for the Applications (â€œAppsâ€) used, but I understand that I will carry my
own costs of any infrastructure and/or running costs associated with such service being
rendered e.g. the data used, the cellular phone, telephone and/or computer, etc.
4. 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 iTelehealth consultation is in my
best interest, provided that it would be safe for me, the Practitioner and others, to do so.
5. That I will be billed for a consultation at a specified rate for [duration of the initial
interaction/consultation] or any part thereof. Additional consultations will attract fees at the
same rate as indicated herein.
6. I also understand that, due to the nature of the current pandemic, that the Practitioner may
have to give urgent attention to other patients, and/or have to move my appointment to a
later or earlier time or day.
7. That my medical scheme may, or may not cover the costs of this care. I undertake to cover
any shortfall that my medical scheme does not cover, which may be the full amount.
However, I understand that the HPCSA allows such care during the time of the Covid
Pandemic, and that certain services must be funded by my scheme in full.
8. To record-keeping of the session i.e. the Practitioners notes, which are required by law
[and, where applicable: ................ and with my prior consent, to the recording of the live
session as video and sound recording.]
9. That the service may have limitations relating to technology, such as data - and internet
failures (e.g. dropped calls or bad reception, internet connectivity issues etc).
10. The Practitioner will adhere to the existing rules relating to confidentiality :
a. I understand that I must take the necessary precautions at home to ensure my
confidentiality during iTelehealth service provision;
b. I understand that, should I want a family member, caregiver, parent or other person to
attend the session with me (in person or through a remote internet connection), I will
provide my written consent to such attendance prior to the consultation. I understand that
without this, should such a person be in attendance, the engagement may be cancelled or
c. I understand that, and agree that, should the practitioner believe that I may have been
exposed to Covid-19 and/or do have Covid-19, she/he would refer me for tests, and I
understand that the results of such tests must be reported, by law, to the NICD (National
Institute of Communicable Diseases).
Or alternatively, download, sign and email the form back to firstname.lastname@example.org