MySexualHealth.co.za - Patient Registration Form

MySexualHealth.co.za Patient Registration Form - Dr. Jeanne Aspeling - Cape Town
Please Complete the form below before your visit to our practice located in Durbanville, Cape Town.
Full Name*
First NameMiddle NameLast Name
By what name would you like us to call you?*
Title:
Your appointment with Dr. Jeanne Aspeling is scheduled at the following address: Hills Medical Centre, Suite 2 Promed Park, 1A Hibiscus Street, Durbanville, Cape Town. (Practice of Dr Muller Smit)*
I Acknowledge that my appointment with Dr. Aspeling is in Cape Town.
Appointment date and time:
MonthDayYearHourMinutesAM/PM Option
Birth Date:*
MonthDayYear
ID Number*
or Date of Birth in the absence of an ID number
Gender*
MaleFemaleTransNon-Conforming
E-mail*
I agree and acknowledge that by providing my email address to MySexualHealth.co.za, I give permission and consent to be sent reminders about my appointments, links to questionnaires, invoices and statement, news from MySexualHealth.co.za, and test results or other information about my appointments and health to this email address. I also confirm that I am the only person with access to this email address, and should I grant access to this email address to any other person, they will be able to access my personal medical information sent to this address.*
I have read, understood and accepted these terms and conditions.
I agree and acknowledge that it is my responsibility to immediately inform MySexualHealth.co.za if my email address changes to ensure the confidentiality of my medical information. I also understand that there are risks involved in using emails, such as interceptability, insecure attachments, information being stored on office email back-up servers, personal password integrity, emails getting “lost”, etc.*
I have read, understood and accepted these terms and conditions.

Contact Details:
Mobile Phone Number*
Area CodePhone Number
Landline Number
Area CodePhone Number
Street Address:
Street Address
Street Address Line 2
CityState / Province
Postal / Zip CodeCountry
Postal Address:*
PO BOX
CityState / Province
Postal / Zip CodeCountry

Do you have a Medical Aid*
YesNo
Medical Aid Details:
Medical Aid Name:
Medical Aid Plan:
Medical Aid Number:
Are you the Main Member?
YesNo
Main Member Name:
First NameLast Name
Main Member ID Number:
Dependant 1:
First NameLast Name
Dependant 2:
First NameLast Name
Dependant 3:
First NameLast Name
Dependant 4:
First NameLast Name

Please upload a copy of your ID document and medical aid card by dragging and dropping the files into the box below. Should you have trouble completing this step, please click next, but please then remember to email us a copy of your ID and medical aid card before your first appointment to cpt@mysexualhealth.co.za.

Next of Kin Details
Name*
First NameLast Name
Telephone Number*
How are you related to this person?
ParentSpouse/PartnerSiblingChildFriendColleague
If the practice needs to contact me, and has not been able to reach me for a reasonable amount of time, I agree and give consent that they may contact my next of kin as listed on my registration form in order to reach me. Under no circumstances will any personal medical information be shared with this person without my consent. I agree and understand that should MySexualHealth.co.za or its representative(s) need to contact my next of kin, the person making the call, will need to clearly identify themselves in order to receive relevant information from my elected next of kin.*
I have read, understood and accepted these terms and conditions.

Consent: Medical
CONSENT TO SUPERVISION: By booking this consultation, I agree to the following terms: Dr. Jeanne Aspeling works under the supervision of Dr. Elna Rudolph, and all patient information, as well as the Healthspace profile of the patient will be made available to Dr. Elna Rudolph in order to assist Dr. Jeanne Aspeling with the treatment of the patient. Please click here to give your consent for doctor supervision:*
I have read, understood and accepted these terms and conditions.
• 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. They are not 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.
Please click here to indicate that you have read, understood and agreed to give Medical Consent:*
I have read, understood and accepted these terms and conditions

Consent: Fees & Charges
CONSENT TO THE FEES BEING CHARGED BY MYSEXUALHEALTH.CO.ZA:
By booking this consultation, I agree to the following terms: • I Acknowledge that I have been informed that Dr. Jeanne Aspeling / MySexualHealth.co.za 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. Jeanne Aspeling / MySexualHealth.co.za charges fees that are over and above the RPL rate, and I understand that the practice my charge fees in excess of my medical scheme’s rates (dependant on plan, benefits structure and current accepted medical scheme networks):
FEES FOR DR. JEANNE ASPELING:
- New Patient: Consultations of up to 25 minutes are charged at R960 (First Visit)
- Follow-up: Consultations of up to 25 minutes are charged at R750 (Only for existing patients)
The following consultations have to be paid via electronic transfer before the appointment can be confirmed:
- Telephonic Update: Consultations of up to 15 minutes are charged at R520 (Only for existing patients)
- Repeat Prescriptions: R285 (only available for patients who have been seen in the last year)
- Email Consultations: R285 (only available for patients who have been seen in the last year)
- Feedback of Results after a visit: R285 (only available for patients who have been seen in the last two weeks). If blood/other samples are taken more than 2 weeks after your last consultation, normal Telephonic Follow-up rates will apply to discuss results with your doctor)
• Administrative Work: R410 per 10 minutes or part thereof (chronic medication applications, special motivations, letter, reports, etc)
• Theatre Use: R200 Facility Fee in addition to the consultation fees.
• Medical records can be made available in print or electronic format, upon request, to patients or to third parties as authorised in writing by the patient. The written consent must state the reason for requiring the information to be supplied to the patient for their own use, or to a third party. The cost of receiving a copy your file will be R300 for the first 10 pages, and an additional cost of R100 for every 10 pages or part thereof there after (excl. vat).
**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.
Please click here to indicate that you have read, understood and agreed to the fees & charges:*
I have read, understood and accepted these terms and conditions.

Consent: Terms & Conditions
• We are a CASH practice. This means you have to pay for your consultation on the day of your appointment. We accept cash, cards or EFT payments prior to or directly after your appointment.
• Please note: Ultrasounds, procedures, consumables, medication and blood tests are not included in these rates. A pap smear or rectal examination is included, but not the laboratory fees. Please inform your doctor at the start of the consultation if you would like a pap smear/prostate examination.
• All appointments including telephonic appointments must be confirmed at least 48 hours before hand. Confirmed appointments that are missed and was not cancelled more than 48 hours in advance, will be charged at the full appointment fee. Cancellation of an appointment with Dr. Jeanne Aspeling / MySexualHealth.co.za must be done at least 2 days in advance. You will be charged for the full appointment if cancellation takes place within less than 2 days prior to the appointment.(Please note: medical aids do not cover missed/cancelled appointments, so this amount will be for your own account and this arrangement is valid for all future appointments.)
• Invoices: Your invoice will not be generated by the receptionist and might also not be generated immediately after your appointment. You can however expect to receive your invoice within one week of your consultation via email, but there might be exceptions to this due to circumstances beyond our control. Please contact us directly at cpt@mysexualhealth.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:
• MySexualHealth.co.za 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. Jeanne Aspeling / MySexualHealth.co.za. 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 MySexualHealth.co.za 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. You will be informed of such credit upon receipt of an account statement from MySexualHealth.co.za, or upon your enquiry. Should you require a refund for amounts credited to MySexualHealth.co.za 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.co.za of any payments that may have erroneously been paid into our account.
I agree and acknowledge that the fees for Dr. Jeanne Aspeling will have to be paid with a debit or credit card/cash on the day of the appointment or via EFT directly after the consultation on the day of the appointment.*
I have read, understood and accepted these terms and conditions.
I agree and acknowledge that cancellation of an appointment with Dr. Jeanne Aspeling / MySexualHealth.co.za must be done at least 2 days before the appointment. If I cancel in less than 2 days, I will be charged for the full appointment. I understand that medical aids do not cover missed appointments, so this amount will be for my own account, and that this arrangement is valid for all my future appointments.*
I have read, understood and accepted these terms and conditions.
I agree and acknowledge that I am responsible for lodging a claim with my medical aid, acknowledging that the responsibility for such a claim lies with me and not with Dr. Jeanne Aspeling / MySexualHealth.co.za. The medical aid will reimburse at least a portion of the payment to me, depending on my specific and available cover.*
I have read, understood and accepted these terms and conditions.
I acknowledge that I am entitled to request a detailed costing estimate related to any planned procedure/treatment at the practice. It is my responsibility to understand my medical aid benefit plan, and to know if written referrals / authorizations are required for consultations or procedures, and what services are covered and available on my policy. Obtaining prior authorisation for services does guarantee its payment. *
I have read, understood and accepted these terms and conditions.
I accept that I am fully responsible for payment for services rendered and should I not pay timeously as set out in my invoice or statement, I understand that I will be liable for debt recovery costs on an attorney and own client scale. *
I have read, understood and accepted these terms and conditions.

Consent: Use of Electronic Health Records
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 our 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 MySexualHealth 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 MySexualHealth uses for all our medical records. This system use 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.
I agree to the terms and conditions above*
Yes, please create a "Patient Profile" for meNo, please do not create a "Patient Profile" for me
Please click here to indicate that you have read and understood that should you choose not to make use of our electronic medical record system, neither you nor your medical professional will have access to your medical information online. Your appointment time will be reduced by 5 to 10 minutes in order for your doctor to be able to peruse your medical records on file. Should you require any medical information, feedback or repeat prescriptions, please allow for 7 to 10 working days for your medical professional to reply to your request.*
I have read and understood this information.

Appointment Arrangements:
• Please scan and email your medical aid card and ID to us at cpt@mysexualhealth.co.za before your visit if you did not upload it onto your registration form. It is your responsibility to ensure we have your correct information and an up-to-date copy of your medical aid card and ID at all times. It is therefore your responsibility to update your personal information as soon as there is a change, and if you fail to provide us with the correct updated information MySexualHealth.co.za will be indemnified against any damages should a breach of privacy occur
• You must confirm your appointment with us at least 3 days or more before the time via email at cpt@mysexualhealth.co.za. If you do not confirm your appointment, it will be cancelled in order to accommodate a patient on our waiting list.
• 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 cpt@mysexualhealth.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. 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 Telephonic or Face-to-Face 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, 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.
• Arrive at least 10minutes before your appointment please. If you suspect that you might have an infection, please ask your doctor for a disposable cup to provide a urine sample. This is also applicable to all your follow-up appointments.
• 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. You will be able to have some coffee/tea, or read the interesting literature available in the waiting room. Our commitment to you is: If you have to wait longer than 30 minutes after your appointment should have started, it will be free!
Please click here to indicate that you have read, understood and agreed to these appointment arrangements:*
I have read and understood this information.

Other Arrangements:
• Repeat prescriptions or treatment advice delivered via email may be requested between appointments. This service is only available to existing patients who has 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 settle the respond appointment fee before the service will be delivered. You will receive an invoice for your respond appointment 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. JEANNE ASPELING – Email Appointment / Prescriptions – R285
- For Treatment Advice or for prescriptions: Please send an email directly to cpt@mysexualhealth.co.za with the subject “RESPOND285” in the subject line. Please attach your proof of payment for R265 to this email for the email consultation.
- Your request will be sent to your doctor, and she will respond to your request directly, provided that your proof of payment was received with your request. This will usually take between 24 to 72 hours.
• Should you request this service 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: MySexualHealth.co.za does not offer emergency services as part our regular service. We can only help you during office hours and if the doctor is available. If we are unable to help you or it is after hours, please see 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 your 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 cpt@mysexualhealth.co.za if you have any questions.
• CHILDREN: If you (the patient) are a minor below the age of 18 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. Consent to all other terms and conditions on this document cannot be agreed to by a minor, and therefore requires the consent of your Parent or Guardian.
Please click here to indicate that you have read, understood and agreed to these other arrangements:*
I have read, understood and accepted these terms and conditions.

I understand and agree that the terms and conditions above may be amended by MySexualHealth.co.za from time to time without notice.*
I have read, understood and accepted these terms and conditions.
Once you submit your registration form, we will contact you shortly to finalise your appointment.
You will also receive an email with 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!
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MySexualHealth.co.za Patient Registration Form - Dr. Jeanne Aspeling - Cape Town

Contact Details:

Medical Aid Details:

Next of Kin Details

Where did you hear about us?

Consent: Medical

Consent: Fees & Charges

Consent: Terms & Conditions

Consent: Use of Electronic Health Records

Appointment Arrangements:

Other Arrangements: