INFORMATION CONSENT FORM

I hereby give consent for my medical doctor, Dr Francois Bruwer, to capture and store all personal information relating to my health records and that of my medical aid dependants, including names, identity numbers, and other personal information, along with details of our medical treatment, medications, medical appointments, procedures and medical aid claims in Dr Francois Bruwer’s patient database and practice management system.

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I confirm that I am authorised to give such consent on behalf of my medical aid dependants. I understand that this personal information may be stored either on site at the practice, or else off-site in a secure encrypted cloud environment managed by a third party.

I understand that Dr Francois Bruwer may need to share my/our special personal information with healthcare service providers, for example: healthcare facilities, my general practitioner/referring doctor, medical aid schemes, x ray department, laboratory, physiotherapist, insurers, administrators and pharmacists, for the purpose of providing me/us with comprehensive, integrated health services and for conducting member checks.

I understand that from time-to-time Dr Francois Bruwer may allow a computer specialist to access his/her patient database which carries my/our personal information for the purpose of updating or repairing the database. I give permission for such temporary sharing, on the understanding that the practice has signed Data Processing agreements with such third parties.

I understand that my/our special personal information will not be shared with any other third party by Dr Francois Bruwer without my/our express, specific, prior permission.

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