Your privacy and confidentiality are safeguarded in accordance with South African legislation, including the South African Constitution, the National Health Act and the Protection of Personal Information Act (POPIA). As a patient at Jentlinc Practice, under the care of Dr. Stephanie Uys, you are requested to provide your informed consent for treatment and the disclosure of information. This information will be used to support medical scheme claims and monitor your progress and care.

Terms of Consent:

1. Age and Capacity: I confirm that I am at least twelve (12) years of age or older, of sound mind, and sufficiently mature to provide voluntary consent for treatment.
2. Consent to Treatment: I voluntarily consent to receive treatment from Dr. Stephanie Uys and her authorized staff. I understand that all treatments may carry certain risks, which have been explained to me.
3. Consent to Use of Personal Information: I consent to the collection and use of my personal information by Jentlinc Practice, which may include, but is not limited to, my name, ID number, address, contact details, medical history, and health information. I understand that this information will be treated as confidential and will only be disclosed to third parties as necessary for medical scheme claims and patient care, as stipulated in paragraph 6 below.
4. Disclosure to Medical Aid: I consent to the disclosure of my medical information, including diagnosis, treatment plans, and recovery progress, to my medical aid. I understand that this may include sharing of personal health information (including ICD-10 codes), and I acknowledge that such disclosure may result in a potential breach of confidentiality.
5. Electronic Records: I understand and consent to my personal and medical information being stored electronically on the Outcomes IT patient record management system, which is hosted on a secure server in South Africa. Jentlinc Practice has ensured that reasonable measures are in place to maintain the confidentiality and security of my information at all times.
6. Medical History: I agree to provide a full and accurate medical history to Jentlinc Practice, including details of any current or previous medical conditions and medications I am taking or have taken.
7. Emergency Treatment: I consent to the arrangement or provision of emergency medical treatment if deemed necessary during my care at Jentlinc Practice.
8. Referral to Healthcare Professionals: I consent to the disclosure of my medical information to other registered healthcare professionals, including doctors, nurses, and social workers, who may be involved in the management of my care.
9. Use of Data for Research and Statistical Purposes: I consent to the use of my de-identified medical information for research, statistical analysis, and funding purposes. I understand that no personally identifiable information will be shared with third parties for these purposes.
10. Student Involvement: If applicable, I consent to receiving treatment from students or interns under supervision, as part of Jentlinc Practice’s accreditation as a training facility with the Health Professions Council of South Africa (HPCSA).
11. Legal and Statutory Rights: This form does not diminish any legal authority or rights vested in any person, court, or statutory body under South African law, regarding access to information.
12. Voluntary Consent: I confirm that my rights have been explained to me, and I have had the opportunity to ask questions about the content of this form. I provide my consent freely, without duress or undue influence. In the case of a minor, my legal guardian has also been informed, has had an opportunity to ask questions, and consents voluntarily.

I hereby authorise, freely and voluntarily and with knowledge of the implications of such consent, the Practice to disclose the specific information outlined herein to the person(s) mentioned and to the extent identified herein.