Health Care User Information

Please note:

  • In terms of the Patients’ Rights Charter, health care related legislation and ethical principles, all health care information provided is protected as confidential and/or private;
  • All patients/clients of health care services (hereafter: the Health Care User), above twelve (12) years of age, may consent to health care services, unless deemed incapable to do so in terms of the law.
A. HEALTH CARE USER INFORMATION
Current address (in residence, if applicable)
Language(s) of health care user
B. HEALTH CARE USER’S NEXT OF KIN
C. STUDENT INFORMATION
Type of support
D. STAFF INFORMATION
Appointment type - Position type
E. HEALTH CARE INFORMATION
Existing medical conditions: Health care user
Immunisation last 10 years
F. COMPLETED & SIGNED
By signing this document, the health care user acknowledges that: 
  • The above information has been provided voluntarily and without reservation;
  • That all health care services:
    • are accessed voluntarily and subject to the informed consent of the health user;
    • are considered confidential and private. Health care information will be dealt with in accordance with health care legislation and applicable ethical principles;
    • are reliant on the active participation of the health care user, including shared decision-making;
    • are to take place in a mutually safe and respectful environment for both the health care user and health care practitioners. The right of admission is reserved.
Sign above