New Patient Form

Privacy policy and Protection of Personal Information (POPIA) notice

The practice uses, discloses, safeguards and retains the personal information obtained during your care in accordance with applicable legislation. By visiting, interacting with or receiving treatment from Dr Forlee and Dr Tunnicliffe, you consent to the following terms from the registration sheet:

1. Your personal information may be collected, processed, recorded and used while medical services are rendered, and must be safeguarded.
2. The practice may add information received from other medical service providers and third parties to provide appropriate care.
3. Information may be verified, shared with and disclosed to third parties involved in care or supplying services or implants, including hospitals, anaesthetists, general practitioners, surgical assistants and paramedical services.
4. You may access the personal information held by the practice once your account is paid up to date. A request may take up to 30 days to process.
5. The information you provide is voluntary.
6. You may ask in writing for information to be updated, corrected or deleted on reasonable grounds.
7. Your information and diagnosis may be disclosed to your medical aid, the billing company (Axialmed), the main member of the account and, where applicable, your broker.
8. If you do not agree to your diagnosis or ICD-10 codes appearing on an account, quote, statement or invoice, give written notice at each visit. Your medical aid may reject a claim and you would then be responsible for payment.
9. Where applicable, your information and diagnosis may be disclosed to the person or entity paying the account, such as a partner or employer.
10. If you object to processing, the practice may cease processing except where reasonably needed to conclude a transaction or outstanding business.
11. If you withdraw consent, the practice may still have to retain information for five years after the relationship ends and may keep medical records for its protection while it remains in practice.
12. The practice may disclose information when required or permitted by law.
13. The practice may record and store audio or video of consultations and surgery for quality and note-taking purposes.
14. Without written consent to obtain information, the practice cannot be held responsible for not obtaining it.
15. Refusing information needed for contractual, legal or legitimate purposes can hinder care; where reasonably justified, the practice may refuse admission, diagnosis or treatment.

Payment terms

This practice charges above NHRPL tariffs and medical aid rates. The person signing is personally responsible for payment, rather than their medical aid. In a divorce, the parent accompanying a minor is responsible for the account. Recovery action may include legal and administration costs and a 20% administration fee on each instalment; defended matters may incur attorney-and-client costs. Once the account is handed over, correspondence is with ARA (Anthony Richards & Associates). The registration sheet states that the National Credit Act 34 of 2005 does not apply to this claim. Your address above is chosen as your domicilium citandi et executandi for this agreement.

By signing, you confirm the details are true and correct and that you have read and agree to these conditions.