TOUCH OF HEALING uy ‘é- Mice Second eames a RN: Wound Care (VOVS) (Cell Nos 0845959070 md a Stone Teapt “ESD Netcare Waterfall Hospital Dear Patient, I would like to thank you for placing your trust in me as an Advanced Wound Care Specialist. ‘To maintain a high level of service to you as a Patient, please take note of the following: Treatment + Al wound care treatments carried out inthe rooms are due to referral from your Doctor. Treatments are in accordance with informing your Doctor, the Wound Care Specialist’s discretion. All the necessary steps will be taken to eliminate and or minimize any potential risks and disadvantages associated with any treatment. However, outcomes cannot be guaranteed, Confidentiality * The Wound Care Specialist may need to divuige certain personal and medical information regarding the patient to ‘ther attending practitioners and administrative staff concerned for purposes elther relating to the treatment of to Process for statistical, epidemiology, managed health care and payment purposes, which indlude sending of the ‘account to the relevant third party payer, funders, administrators and switching companies, if applicable. + These practitioners and administrative will have access to the personal medical records on a “need to Know’ basis. Patient confdentiaty will be protected at al casts, but absolute confidentiality cannot be guaranteed. As far as Possible the information will be deatt with in a confidential manner. Signed: Tariffs and Accounts + You will be responsible for our usual fees charged, which we feel are commensurate with the service and standard of care we aspire to offer. Medical aid details are required so you can daim payment from your scheme, this reimbursement isin line withthe plan/option you have chosen. «IF you are unsure about possible financial implications of your treatment, please discuss with myself or Sonja Strydom (Practise Manager). If necessary, arrangements can be made but prior to 30 days and a confirmation letter of debt needs to be signed. + Accounts are emailed or printed out and given to patient's directly. If you do not timeously receive an account, the responsibilty remains with you to pay the account ~ you are most welcome to phone the office on 0113046817/16 and inquire at any time as to outstanding bakances. “TF your GP has requested that you have an expedited appointment Le. you need to be seen the same day or if you need to be seen after hours, we reserve the right to apply a levy for elther an emergency or unscheduled appointment, depending on the nature of the situation. * We reserve the right to charge for motivations with a cost of R500 per letter. Signed: Consent + Thereby give consent to wound care treatment, as prescribed by my Doctor. I also acknowledge that the wound care and/or format of treatment can change, according to availabilty and my specific medical needs. + | give permission to enter ICD10 codes (diagnostic codes) on all accounts processed, as ths Is a legal requirement by the Council of Medical schemes. ‘give this consent freely and dedlare that it was not made under duress, + Its my right to withdraw this consent at any time of for any specific procedure of modality, ater discussion with ‘my wound care specialist and Doctor. + Images (digital, flm, etc.) may be done by the Professional Nurse Practitioner - ofthe patient and all the patient's wounds with ther surrounding anatomical features. The purpose ofthis isto: > Monitor wound care progress and to ensure continuity of care, > That thei referring physician or other treating physicians may receive communication, including images, with regards to the patient's treatment plan and results. > The imagery, without isciosing identity ofthe patent, may be used for the purposes of education, research, quality assessment or improvement strategies in wound care. Signed: Please acknowledge that you understand and agree to the terms and conditions mentioned above Date: Signature: 21Page