To supplement consent to consultation / treatment

I, the undersigned patient, or person authorised to consent on behalf of- a child younger than 12 years / -a patient who is incapable of consenting, hereby state that I understand, and agree to the following:

  1. I am authorised, either by being a patient 18 years or older, or by a law, to provide this consent.
  2. This consent form supplements the general consent I provide when agreeing to health care, treatment, evaluation and/or consultation.
  3. COVID-19 is a virus that is highly infectious, and can spread from person to person, and survive on surfaces. I understand that as a patient / parent / authorised person, I have a responsibility to ensure that all rules set by the National Institute for Communicable Diseases (NICD - and the National Department of Health, are followed. 
  4. It is understood and agreed to, that no guarantees can be made that the virus will not be transmitted in a practice. It is also understood that asymptomatic persons may transmit the virus.
  5. All patients and accompanying or authorised persons will be required to complete a screening survey prior to the consultation and/or treatment taking place. The results of this screening survey may necessitate that the patient and/or accompanying person be referred for a COVID-19 test. Should the test come back positive, a decision will be made as to the cancellation of any care to be provided. It is understood that the results of such a COVID-19 test, or any screening that reveals a person who might have been exposed to the virus, must by law, be reported to the authorities (the NICD). This includes the duty to supply all contacts one has had.
  6. The Practice may require strict adherence to specific protocols to protect the patient and HCP (health care practitioner), and any accompanying person. Practice protocols include that only one patient will be allowed in the practice at any point in time, and that persons have to wait in their car or in the parking lot until called in.  See Addendum A
  7. No unannounced visits to the Practice are permitted.
  8. Physical examinations require the HCP be in close proximity to the patient. The HCP and other staff, such as assistances, may wear protective clothing that could be a medical mask, gloves, a face shield and/or special protective clothing. Different staff or professionals may wear different types of protective clothing, depending on the nature of their work.
  9. Accompanying persons must adhere to physical distancing rules at all times, with a cloth face mask on at all stages (
  10. The cost of care may be different due to the longer duration of preparing for care, or the actual care itself during the time of COVID-19. The patient or responsible person takes full responsibility to cover all costs not covered by the medical scheme or other third-party funder.
  11. The HCP will as part of the booking advise and communicate as to what is required of patients and/or accompanying persons, and such patients and persons agree to adhere to such advisories, and release the Practice from legal liability should they decline to do so.
  12. If health care (investigation, consultation, treatment and/or consultation) is refused or delayed by the patient/authorized person, in spite of being recommended by the HCP, the patient / parent / authorised person confirms that s/he has been informed of the implication of such refusal or delay, and releases the HCP from legal liability should any harm result from such a refusal or delay.