Patient Registration Form - Dr. Larisse Badenhorst - Telehealth

You can use any name if you prefer to remain anonymous.

• I understand and agree that diagnostic and procedural information (as well as any related photographs) related to my treatment may be utilised for practice statistical, research and/or teaching purposes. All such information will be dissociated from my personal patient information. Informed consent will be obtained by the practice if any of my information is required for clinical trials or research projects.

• I agree and authorise the practice to provide any information concerning my treatment at this practice, including but not limited to current conditions/comorbidities to my medical scheme, their managed healthcare organisation and/or their respective agents dealing with my treatment. Should any of the aforementioned parties also be my employer, then I understand that the information may also be available to my employer.

• I understand and agree that the practice issues invoices, statements and prescriptions that include diagnostic and/or procedural information such as procedural tariff codes and/or ICD10 codes, which indicates my diagnosis, according to legal requirements prescribed by Medical Schemes provided for in the Medical Schemes Act No. 131 of 1998. I understand that this means that if I submit invoices to my medical aid they will have access to the diagnostic and/or procedural information on the invoice. I understand that should I decide not to disclose my diagnosis to my Medical Aid, I should refrain from submitting such invoices, statements and prescriptions to my Medical Aid for claims purposes. I acknowledge that I am welcome to discuss my diagnoses and diagnosis code (ICD10 Code) with my doctor.

• I understand and agree that if I am not the main member on my Medical Aid policy, submitting invoices and statements from the practice as mentioned above, it is possible that diagnostic and/or procedural information such as procedural tariff codes and/or ICD10 codes, which indicates my diagnosis, can be disclosed to the main member on my Medical Aid policy.

CONSENT TO ALTERNATIVE, UNREGISTERED or COMPOUNDED TREATMENT:

• I understand and agree that my doctor might prescribe a treatment for me that might be seen as alternative.  It might also not be registered for use in males or female in South Africa.  It might be so-called “off-label” medication, meaning that it is not used for the purpose that it was registered for.  The treatment might also be compounded by a compounding pharmacy according to a specific recipe prescribed by my doctor.  I am welcome to ask my doctor whether the suggested treatment is seen as conventional or alternative.  Conventional medication is always preferred, unless the patient only wants natural, herbal or bio-identical treatment or if there is no conventional/registered option available for the specific condition. I am welcome to ask questions about my prescribed treatment until I am satisfied that I have enough knowledge to make an informed decision about it.  My doctor will offer all available treatment plans for my condition and might make suggestions, but it is my right to accept or refuse any treatments. Dr Larisse Badenhorst commits to not being offended if I ask questions and request more information.                 

• I understand and agree that I should take medication exactly as it is prescribed by my doctor.  If I decide not to take certain treatments due to side-effects or for any other reason, I run the risk of serious complications, varying in severity, but can include cancer and death.  If I have difficulty taking my medication as prescribed, it is recommended that I rather contact my doctor.

CONSENT TO THE FEES BEING CHARGED BY DR ELNA RUDOLPH:

By booking this consultation, I agree to the following terms: • I Acknowledge that I have been informed that Dr. Larisse Badenhorst does not charge the rates that the Department of Health has unilaterally determined for doctors and which are known as the Reference Price List (RPL); • I Confirm that I am aware that the RPL values for services are available from the Department of Health (Tel: 012 312 0000) and the Health Professions Council of South Africa (Tel: 012 338 9300) and www.doh.gov.za ; • Confirm that I am aware that Dr. Larisse Badenhorst charges fees that are over and above the RPL rate, and I understand that the practice will charge fees in excess of my medical scheme’s rates:

TELEPHONIC CONSULTATION FEES FOR DR. LARISSE BADENHORST:

• Fees have to be paid up front in order to secure your appointment.
• Telephonic appointments New Patients MSH: Consultations of up to 30 minutes are charged at R750 (First Visit)
• Follow-up MSH: Consultations of up to 15 minutes are charged at R550 (Only for existing patients)
• GP patients: R500 (15 minutes)

**The fees quoted in the terms and conditions above may be adjusted from time to time without notice. This includes the annual fee adjustment that will take effect on 1 March each year.

CONSENT TO THE TERMS AND CONDITIONS OF DR ELNA RUDOLPH:

• All appointments including telephonic appointments must be confirmed at least 24 hours before hand. Appointments that are missed and was not cancelled more than 24 hours in advance, will be charged at the full appointment fee. (Please note: medical aids do not cover missed appointments, so this amount will be for your own account and this arrangement is valid for all future appointments.)

• We are a CASH practice. This means you have to pay for your consultation BEFORE your appointment via EFT, bank deposits or vouchers from MySexualHealthSHOP.

• Please note: Procedures, consumables, medication and blood tests are not included in these rates. 

You can expect to receive your invoice within one day of your consultation via email, but there might be exceptions to this due to circumstances beyond our control. Please contact us directly at jhb@nysexualhealth.co.za or reception@wellgp.co.za if you would like to get your invoice urgently. Keep in mind that you have up to four months to submit your invoice to your medical aid.

Medical Aid:

• WellGP/MSH/Dr Larisse Badenhorst does not submit invoices/statements for claims to medical aids on your behalf.  You will be responsible for lodging a claim with your medical aid, and the responsibility for such a claim does not lie with Dr Larisse Badenhorst. You will be invoiced directly and you can then claim back a portion of the fee from your medical aid according to your specific and available cover.

• It is your responsibility to submit the invoice together with the proof of payment to your medical aid for them to reimburse you. Should your medical aid reimburse MSH/WellGP after you have settled your account with us, or there is a credit on your account for any reason whatsoever, that amount will stay in credit on your account with MySexualHealth/WellGP. You will be informed of such credit upon receipt of an account statement from MySexualHealth/WellGP, or upon your enquiry. Should you require a refund for amounts credited to MySexualHealth/WellGP in excess of your outstanding balance with us, or your Medical Aid requested a refund from us, an administration fee of R50 will be charged to recover banking and administration fees. The onus remains on the patient to inform MySexualHealth/WellGP of any payments that may have erroneously been paid into our account.

By giving consent herewith, I agree to let Healthspace (PTY) Ltd ("Healthspace"/"we/us") retain and/or host my personal information and medical history on their Website http://www.healthspace.co.za and consent to my personal information and medical history being viewed by my healthcare professional(s).

[Complete terms and conditions and privacy policy are available at https:/www.healthspace.co.za/termsandconditions.html]  

1. • My Personal Information - These are items of personal information that will be retained by Healthspace and viewable on the Website by my healthcare professional 

     • My Electronic Health Record - These are the details of my medical history that I consent to let my healthcare professional enter on my electronic health record on the Website:  

1.1 My medical condition: My general state of health, as well as any conditions I suffer from, including chronic conditions;  

1.2 Test results: Any test results relating to my medical condition;  

1.3 Relevant information: Any other information my healthcare professional may deem as relevant in helping me to manage my medical condition. 

2. To whom does Healthspace disclose this information? 

2.1 Healthcare Professionals: My healthcare professional has access to my personal and medical information. In addition you may authorise other registered healthcare professionals registered on the Website to have access to my personal and medical information on the Website; and  

2.2 Healthspace: as the operator of the Website on which my personal and medical information is stored, they have access to my personal and medical information. 

3. What Healthspace does with this information? 

3.1 The personal and medical information provided by me and my healthcare professional is used to create a "Patient Profile" that allows both me and my healthcare professional to access and view my patient file information stored on the Website which may include but is not limited to information relating to:  

3.1.1 my diagnosis and/or medical condition(s);  

3.1.2 treatment provided to me by my healthcare professional;  

3.1.3 medicines prescribed to me by my healthcare professional;  

3.1.4 clinical notes drafted by my healthcare professional; and  

3.1.5 results of any medical tests. 

By marking the appropriate button below I confirm that:  

1. I agree to and understand the terms of this Consent Form.

2. I give consent that a "Patient Profile" may be created for me by My Sexual Health with a generic password.

3. I confirm that I will change this generic password for my "Patient Profile" upon receipt of my registration email to ensure the security of my medical information.

Please note: This is the system that Dr Larisse Badenhorst uses for all her medical records. This system uses the same type of security that banking websites and other secure websites use known as a Premium EV SSL Certificate. You can verify this by looking at the web address which starts with https:// instead of http://, the lock displayed in the address bar, and the security stamp at the bottom of the page, which all indicate that it is a secure site.

Please consider carefully the ramifications of not allowing us to utilise this tool.  Dr Larisse Badenhorst can not conduct online/telephonic consultations wihtout and electronic medical record for you.

• Please confirm your appointment with us at least 24 hours or more before the time via email at jhb@mysexualhealth.co.za OR reception@wellgp.co.za .

• You will receive an email from us stating the exact date, time and venue of your consultation, requesting you to confirm your appointment. If you did not received it, please insist on one. If there are any discrepancies between the email you received and what you were told at the time you made your appointment, please phone the office to clear up the discrepancies.  There is nothing more frustrating for you and for us than can confusions around appointment times!

• Please let us know if you had any blood tests done recently, and obtain a copy of your results from the lab where the tests were done or from the doctor that first ordered the tests. Please make sure that you email these results to us before your appointment at jhb@mysexualhealth.co.za OR reception@wellgp.co.za . Please follow up with us the next day to make sure we received your results and uploaded them onto your profile to ensure the best use of your time during your appointment, especially if your tests were done at a lab other than Lancet. If you cannot email them, please bring them with you to your appointment.

• We strongly advise that you have blood tests done before you see your doctor.  Please refer to the form “Blood Tests Required” to determine what the right tests will be for you.  Please note that if tests are ordered during your consultation, a separate  consultation must be scheduled to discuss the test results, which will be charged at the standard rates.  In some cases, where results are completely normal and no further actions are required, no follow-up consultation will be necessary. 

Please note that we do not operate on the "no-news-is-good-news" principle.  We always inform patients of their test results.  If you do receive feedback from us within one week of sending in a sample, please contact the office to follow-up your results.  We will always inform you about normal results via email and schedule follow-up appointments to discuss abnormal results.

• Should you be instructed to go for blood tests after your first appointment, and you decide not to use Lancet Laboratories, please phone our rooms after 3 days, or before your appointment (whichever is applicable) to check if we received your results and uploaded them onto your profile.

• We do respect your time and it is not our intention to keep you waiting. Our day is also much nicer if we are on time! It is unfortunately sometimes unavoidable to run late. We will inform you if we are more than 15 minutes late.

• Repeat prescriptions or treatment advice delivered via email may be requested between appointments. This service is only available to existing patients who have seen their doctor within the last year (12 months), and if you and your doctor are both satisfied that the matter can be resolved via this method. You will be required to pay the prescription fee before the service will be delivered.   You will receive an invoice for your prescription via email which you can use to claim from your medical aid. Email prescriptions are acceptable in many cases, but where original signatures are required, special arrangements will need to be made to collect/deliver the original prescription.

• DR LARISSE BADENHORST – Email Appointment / Prescriptions – R300

• Should you request a script or advice  from your doctor, please look out for an email from “My Healthspace" no-reply@healthspace.co.za – this is an email sent directly from your patient file on Healthspace, and will contain your prescription, or feedback from your doctor. Please add this email address to your safe list on your email client (such as Outlook) in order to ensure that you always receive communications from your doctor.

• EMERGENCIES: My Sexual Health/Well GP/Dr Larisse Badenhorst do not offer emergency services as part our regular service. We can only help you during office hours and if the doctor is available. You are welcome to phone and explain your situation to the admin staff, who will try to accommodate you if it is possible. If you have a very urgent matter, please phone the office directly to be helped immediately, if possible. If we are unable to help you or it is after hours, please visit your GP or go to the Emergency Unit of your nearest hospital. 

• ACCOUNTS: Should you see your doctor at more than one practice, or see multiple doctors, please be aware of the banking details on your specific invoice when you make payments. Payments made into wrong accounts will however be allocated correctly, but the time it takes to reflect on your statement will be increased. PLEASE NOTE: You might receive more than one statement with different amounts from My Sexual Health during a statement run, as each practice and each doctor has a different bank account. Please compare the information on the different statements with each other in order to distinguish between the different accounts with us. Please contact us on jhb@mysexualhealth.co.za OR reception@wellgp.co.za if you have any questions.

• CHILDREN: If you (the patient) are a minor below the age of 12 years, all terms and conditions in this document must be agreed to by your Parent or Guardian on your behalf. The Children's Act allows sufficiently mature children of 12 years of age to consent to medical treatment since April 2010. If you are a minor over the age of 12 years, you will be able to consent to medical treatment with your doctor if your doctor is satisfied that you sufficiently understand the options, risks and implications of your treatment. 

Once you submit your registration form, we will contact you shortly to finalise your appointment. 

You can request a copy of your submission, as well as a user friendly version of our terms and conditions after submitting this form.

You will find a copy of the most recent version of our full terms and conditions on the "About" page of our website at www.mysexualhealth.co.za/about at all times for your convenience.

Thank you!