TOESTEMMING / CONSENT

TOESTEMMING / CONSENT

Ek, die ondergetekende / I, the undersigned
Volle name & van / Full names & surname
xxx hiermee toestemming vir die volgende / hereby consent to the following:
1.	Die uitvoer van enige prosedure xxxx xxxx my toestand benodig om dit te behandel of te diagnoseer wat kan insluit: ponsbiopsie / eksisie / kurettasie en kauterisasie / photodinamiese terapie / UVB terapie / krioterapie. Die toestemming geld vir so lank as wat ek ‘n pasiënt van Xx XX Xxxxxxx is.		1.	The execution of any procedure as required by my condition for treatment or diagnosis which can include: punch biopsy / excision / curettage and cauterization / photodynamic therapy / UVB therapy / criotherapy. This consent applies for as long as I am a patient of Xx XX Xxxxxxx.
	Ek is bewus van wat die prosedure behels xxxx xxxx die xxxxxx aan my verduidelik of die inligting wat deur die webblad verskaf is.			I am aware of what the procedure entails as explained to me by the doctor or information provided by the website.
	Ek onderneem om enige onduidelikheid met betrekking tot die prosedure of die komplikasies daarvan vooraf met die xxxxxx xx bespreek.			I undertake to discuss any uncertainties and complications relating to the procedure beforehand with the doctor.
	Indien ek nie van die prosedure gebruik xxx xxxx xxx, xxx ek die dokter skriftelik daarvan in xxxxxx xxxx xxxx op die vorm, daarvoor bedoel, aan my verskaf.			In the event that I do not want to proceed with the procedure, I will notify the doctor in writing on the form provided to me.
2.	Die doen van dermatoskopie en “molemapping” wat insluit die neem en xxxxx van foto’s van verdagte letsels op my liggaam.		2.	Doing dermoscopy and molemapping that includes taking and storing photos of suspicious lesions on my body.
3.	Die neem van foto’s van my dermatologiese toestand indien dit benodig word vir toekomstige behandeling en opvolg. Ek stem toe dat hierdie foto’s moontlik aan ander dermatoloë en mediese fondse gewys mag word indien dit nodig is vir die maak van ‘n diagnose of indien dit benodig word vir verdere mediese behandeling en chroniese medikasie aansoeke.		3.	Taking photos of my dermatological condition if needed for future treatment and follow-up. I agree that these photos may be shown to other dermatologists and medical aids if this is necessary to make a diagnosis or needed for further treatment and chronic medication applications.
4.	Die bekendmaking van mediese en persoonlike kontakbesonderhede, asook ICD10 kodes, mediese geskiedenis, bloedresultate, histologie resultate en waar nodig foto’s aan mediese fondse, xxxxx xxxxxx, insluitende patoloë en apteke asook MFI vir verwysings doeleindes asook die vereffening van rekeninge.		4.	The disclosure of medical and personal contact details, as well as ICD10 codes, medical history, blood test results, histological results and where necessary photos to medical aids, other medical professionals including pathologists and pharmacies also MFI for reference purposes as well as the settlement of accounts.
	Die pasiënt onderneem om die praktyk in xxxxxx xx stel van:			The patient undertakes to notify the practice of:
a.	Die versoek om ‘n kwotasie voor prosedures of konsultasies.		a.	The request of a quotation prior to procedures or consultations.
b.	Wanneer hy inligting verlang oor:		b.	When he wants information about
	• Wanneer ‘n rekening betaal word			• Account settlement date
	• Kortings			• Discounts
	• Vorme van betaling			• Payment options
	• Kontakbesonderhede vir betalingsprobleme			• Contact details in the event of problems with payments.
c.	Onttrekking van toestemming met betrekking tot bogenoemde en dit xxx skriftelik doen.		c.	Written withdrawal of consent regarding above.
Geteken te / Signed at		op / on
Pasiënt / Patient		Verantwoordelike persoon / Responsible person