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Indemnity Form

Full Terms & Indemnity

INFORMED CONSENT TO NATUROPATHIC TREATMENT AND GENERAL INDEMNITY

As a patient I have the right to be informed about my health condition(s) and the recommended consultations, examinations and treatments. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care with naturopath, Dr. Francois du Toit and associates (hereafter referred to as Naturopath,) having had the opportunity to discuss the potential benefits, risks and hazards involved.

I, (‘The Undersigned, acknowledged in this digital form’), hereby request and consent to the treatment, consultation and examination (or on the patient named below, for whom I am legally responsible) by Naturopath, as deemed necessary by Naturopath.

I understand my rights as a patient (attached on next page) and understand my right to:

  • ask any and all questions about my diagnosis(es), condition(s) and treatment/treatment plans (including benefits, risks, likelihood of success, alternatives, and consequences if treatment is not followed).
  • participate in decisions regarding my health or the health of whomever I am legally responsible.

Should I have any questions or concerns, or should I experience any side effects from treatment given, I will immediately notify and inform the naturopath. My failure to raise concern will create the assumption that I am satisfied with the service provided and not experiencing any side effects/discomforts to the treatment provided.

For your safety, it is vital that you alert Naturopath of confirmed or suspected pregnancy, bleeding disorders, pacemaker, implants, and/or cancer.

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 understand my naturopath’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

I further understand that access to the premises of the naturopath and the use of all facilities is done at my own risk. Neither the owner of the premises nor the naturopath 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 naturopaths and all employees in their service, agents and/or temporary workers against any liability for loss or damage of any kind whatsoever.

I understand and accept that during these extraordinary times of the COVID19 lockdown, I consent to being consulted with via telemedicine, involving the use of electronic communications. I also understand and accept that there are potential risks involved in telemedicine (such as insufficient information transmitted which does not allow for accurate diagnosis, delays in the consultation due to any electronic problems and more) for which Naturopath is not liable. Benefits of telemedicine may include safer access to naturopathic care as it limits outside contact.

I further note my right to withdraw my consent at any time for any specific procedure and/or treatment.

According to the National Patients’ Rights Charter, every patient has the right to:

  • A healthy and safe environment that will ensure their physical and mental health or well-being.

  • Take part in deciding on matters affecting one’s health.

  • Proper emergency care at any health care facility.

  • Treatment and rehabilitation.

  • Special needs care, especially newborn infants, children, pregnant women, the aged, disabled persons, patients with chronic pain, people living with HIV/AIDS.

  • Counselling without discrimination, intimidation or violence on matters such as reproductive health, cancer or HIV/AIDS.

  • Affordable and effective care for people in the final stages of their lives.

  • Friendly health care providers.

  • Health information in their language of choice.

  • Knowledge of health insurance and medical aid schemes.

  • Choose their own health care provider or health facility.

  • Be treated by a clearly identified health care provider.

  • Confidentiality and privacy concerning health care issues and treatment.

  • All information regarding their illnesses, treatment and the costs involved.

  • Refuse treatment verbally or in writing.

  • Be referred for a second opinion to a healthcare professional of their choice.

  • Continuous care.

  • Complain about health services, have their complaints investigated and to receive a full response.

All patients need to:

  • Take care of their health.

  • Care for and protect the environment.

  • Respect the rights of other patients and health providers.

  • Use the health care system properly and not abuse it.

  • Know his or her local health service and what they offer.

  • Provide health care providers with the relevant and accurate information for diagnostic, treatment, rehabilitation or counselling purposes.

  • Advise the health care providers on his or her wishes regarding death.

  • Comply with treatment or rehabilitation procedures.

  • Ask about the related costs of the treatment and /or rehabilitation and arrange for payment.

  • Take care of any health records they may have.

Comprehensive health care is a joint responsibility between the patient and the medical team. To achieve better health results, patients must understand their illness, follow their treatment and discuss any concerns or disagreements they might have with their health care workers.

(INFORMATION FROM: https://www.westerncape.gov.za/general-publication/heres-what-you-need-know-about-patients%E2%80%99-rights-charter)


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Full Terms & Indemnity

INFORMED CONSENT TO NATUROPATHIC TREATMENT AND GENERAL INDEMNITY

As a patient I have the right to be informed about my health condition(s) and the recommended consultations, examinations and treatments. This disclosure is to help me become better informed so that I may make the decision to give, or withhold, my consent as to whether or not to undergo care with naturopath, Dr. Francois du Toit and associates (hereafter referred to as Naturopath,) having had the opportunity to discuss the potential benefits, risks and hazards involved.

I, (‘The Undersigned, acknowledged in this digital form’), hereby request and consent to the treatment, consultation and examination (or on the patient named below, for whom I am legally responsible) by Naturopath, as deemed necessary by Naturopath.

I understand my rights as a patient (attached on next page) and understand my right to:

  • ask any and all questions about my diagnosis(es), condition(s) and treatment/treatment plans (including benefits, risks, likelihood of success, alternatives, and consequences if treatment is not followed).

  • participate in decisions regarding my health or the health of whomever I am legally responsible.

Should I have any questions or concerns, or should I experience any side effects from treatment given, I will immediately notify and inform the naturopath. My failure to raise concern will create the assumption that I am satisfied with the service provided and not experiencing any side effects/discomforts to the treatment provided.

For your safety, it is vital that you alert Naturopath of confirmed or suspected pregnancy, bleeding disorders, pacemaker, implants, and/or cancer.

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 understand my naturopath’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

I further understand that access to the premises of the naturopath and the use of all facilities is done at my own risk. Neither the owner of the premises nor the naturopath 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 naturopaths and all employees in their service, agents and/or temporary workers against any liability for loss or damage of any kind whatsoever.

I understand and accept that during these extraordinary times of the COVID19 lockdown, I consent to being consulted with via telemedicine, involving the use of electronic communications. I also understand and accept that there are potential risks involved in telemedicine (such as insufficient information transmitted which does not allow for accurate diagnosis, delays in the consultation due to any electronic problems and more) for which Naturopath is not liable. Benefits of telemedicine may include safer access to naturopathic care as it limits outside contact.

I further note my right to withdraw my consent at any time for any specific procedure and/or treatment.

According to the National Patients’ Rights Charter, every patient has the right to:

  • A healthy and safe environment that will ensure their physical and mental health or well-being.

  • Take part in deciding on matters affecting one’s health.

  • Proper emergency care at any health care facility.

  • Treatment and rehabilitation.

  • Special needs care, especially newborn infants, children, pregnant women, the aged, disabled persons, patients with chronic pain, people living with HIV/AIDS.

  • Counselling without discrimination, intimidation or violence on matters such as reproductive health, cancer or HIV/AIDS.

  • Affordable and effective care for people in the final stages of their lives.

  • Friendly health care providers.

  • Health information in their language of choice.

  • Knowledge of health insurance and medical aid schemes.

  • Choose their own health care provider or health facility.

  • Be treated by a clearly identified health care provider.

  • Confidentiality and privacy concerning health care issues and treatment.

  • All information regarding their illnesses, treatment and the costs involved.

  • Refuse treatment verbally or in writing.

  • Be referred for a second opinion to a healthcare professional of their choice.

  • Continuous care.

  • Complain about health services, have their complaints investigated and to receive a full response.

All patients need to:

  • Take care of their health.

  • Care for and protect the environment.

  • Respect the rights of other patients and health providers.

  • Use the health care system properly and not abuse it.

  • Know his or her local health service and what they offer.

  • Provide health care providers with the relevant and accurate information for diagnostic, treatment, rehabilitation or counselling purposes.

  • Advise the health care providers on his or her wishes regarding death.

  • Comply with treatment or rehabilitation procedures.

  • Ask about the related costs of the treatment and /or rehabilitation and arrange for payment.

  • Take care of any health records they may have.

Comprehensive health care is a joint responsibility between the patient and the medical team. To achieve better health results, patients must understand their illness, follow their treatment and discuss any concerns or disagreements they might have with their health care workers.

(INFORMATION FROM: https://www.westerncape.gov.za/general-publication/heres-what-you-need-know-about-patients%E2%80%99-rights-charter)

 

 

 

 

 

 

 

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