NARKOTISEUR
OOREENKOMS TUSSEN DIE ANESTESIOLOOG EN PASIËNT AGREEMENT BETWEEN THE ANAESTHESIOLOGIST AND PATIENT
PASIËNT:
A1. Ek begryp dat ‘n insidentvrye narkose nie gewaarborg kan word nie.
A2. Ek begryp dat teatertoerusting en personeel deur die hospitaal verskaf word. Narkosetoerusting word daagliks getoets.
A3. Ek onderneem om nie alkohol te gebruik, ‘n motorvoertuig te bestuur, sosiale media te gebruik, om die alleen-verantwoordelike xx xxxx vir ‘n baba of minderjarige kind, enige gevaarlike toerusting te hanteer, belangrike besluite te neem of dokumente te teken vir ‘n tydperk van 24 uur nadat narkose toegedien is nie.
A4. Xx xxxxxxx toestemming dat my persoonlike inligting bekend gemaak mag word aan belanghebbende instansies, xxxx xxxx die wet bepaal, asook anonieme data van ‘n kliniese en praktykbesturende aard wat tot die bevordering van die pasiënt se welstand mag bydra.
A5. Ek stem toe tot die verwerking van my persoonlike en gesondheidsinligting ten einde behoorlike behandeling aan my te verskaf, en/of vir administratiewe doeleindes deur die betrokke inrigting of professionele praktyk. Hierdie toestemming betrek ook die verantwoordelike partye wat optree as diensverskaffers aan die inrigting of professionele praktyk.
A6. In die geval van enige eis, klagte of grief, xxx ek voordat ek enige regsaksie neem, gebruik maak van ʼn gratis en konfidensiële premediasievergadering met ʼn geakkrediteerde bemiddelaar aangewys deur South African Society of Anaesthesiologists (SASA).
A7. U narkose rekening is totaal onafhanklik van enige ander rekening wat deur die hospitaal of chirurg uitgereik word.
A8. Die koste (beraming) vir die narkose is met my bespreek.
A9. Die koste (beraming) xxxx uiteengesit in xxxx C is gebasseer op hoe lank die prosedure xxx duur , en mag xxxxxxxx xxxxx onvoorsiene omstandighede of onverwagte komplikasies.
A10. U is persoonlik verantwoordelik vir betaling van u rekening en nie u mediese fonds nie. U mediese fonds mag dalk nie die hele bedrag dek nie, afhangend van die mediese fonds en die plan opsie wat u gekies het.
A11. Sou u rekening oorhandig word vir invordering, xxx xxxxx van 2% per maand gehef word op alle agterstallige bedrae. Alle koste verbonde aan die invordering xxx van u verhaal word teen prokureur en kliënte skaal.
Ek het bostaande gelees, begryp en aanvaar die voorwaardes xxxx uiteengesit.
Ek verklaar dat ek by my volle verstand is ten tye van ondertekening en dat ek dit
uit vrye wil doen. Hiermee xxx xx toestemming vir narkose vir myself of my afhanklike.
GETEKEN: DATUM:
PATIENT:
Anaesthesiologist
A1. I understand that no one can guarantee an incident free anaesthetic.
A2. I understand that the theatre staff and equipment are supplied by the hospital. Anaesthetic equipment is checked on a daily basis.
A3. I agree not to drink alcohol, drive a car, utilise social media, be responsible as a sole care provider for infants/small children,
operate any dangerous equipment, make important decisions or conclude agreements for 24 hours after recovering from anaesthesia.
A4. I agree to allow my personal data to be forwarded to the relevant organisations as required by law and to allow anonymous data of a clinical and practice management nature, to be collected to help to improve the patients healthcare experience.
A5. I agree to the processing of my health and personal information in order to provide me with proper treatment, care and/or for the administration of the institution or professional practice concerned. This consent would extend to responsible parties acting as service providers to the institution or professional practice concerned..
A6. In the event of any claim, complaint or grievance, I shall prior to taking any legal action, promptly initiate a free and confidential pre-mediation meeting with an accredited mediator appointed by South African Society of Anaesthesiologists (SASA).
A7. Your anaesthetic account is rendered completely independently from the accounts rendered by the hospital and the surgeon.
A8. The make up of the cost estimate for the anaesthetic service has been discussed with me.
A9. The cost estimate as set out in section C is time-based and may change as a result of unforeseen circumstances and unexpected complications.
A10. You are personally responsible for payment and not your medical scheme. Your medical scheme may not cover the full amount on your account, depending on the medical scheme and the plan option which you have chosen.
A11. Should your account be handed over for collection, interest will be charged at 2% per month on all outstanding amounts. All costs incurred to collect the arrears will be for your account on attorney and client scale.
I have read, understood and agree to the conditions mentioned above. I declare that I am of sound mind at the time of signing this agreement and that I am not under duress. I hereby give permission for anaesthesia on myself or my dependant.
SIGNED: DATE:
XXXXX XXXXXXXX: COST ESTIMATE:
Do you smoke or use an E-cigarette? (if so, how many per day?) Rook u, of maak u gebruik van ‘n E-sigaret? (hoeveel per dag?)
Is there anything else your anaesthetist should know?
Is daar enigiets anders wat u narkotiseur behoort te weet?