Terms & Conditions and Acknowledgement of Medical Services
I the undersigned, ____________________________________________ (Full Names: patient/guarantor) from the address as aforesaid being my/our and/or the patient’s/guarantor’s chosen domicilium citandi et executandi, hereby consent to medical services to be rendered to myself/the patient, alternatively to one of the guarantor’s beneficiaries (being your minor child/ren and/or spouse and/or medical aid beneficiary/ies.
- S Holt Inc is the doctors’ practice managing this Telemedicine service with the following registered details, and trading under the name and style of S Holt Inc. – Practice Number: 0140000055611
- S Holt Inc and its doctors are governed and regulated by the regulatory Body of the Medical Profession and the Health Professions Council of South Africa.
- All doctors employed by S Holt Inc are registered for Independent Practice with the Health Professions Council of South Africa.
- S Holt Inc is dedicated to providing an efficient and effective service to our patients. If you the patient/guarantor feel that this is not the case, please contact our info email address (firstname.lastname@example.org) to register your satisfaction or dissatisfaction with the service.
- Should you wish to make a complaint against one of our doctors for ethical or professional reasons, you are asked to contact the Health Professions Council of South Africa (Tel no: 012 338 9300) to register a formal complaint.
- By acknowledging this form you the patient and/or guarantor agree to allow S Holt Inc or its agents to contact you via telephone, sms, or email in order to resolve any financial or medical related matters.
- Information contained on the S Holt Inc website, explains the fees charged by this practice. If you are uncertain of the fees, with respect to any aspect of your care in this service, please ensure that you consult with the doctor or the administrative staff that can be reached on 087 845 1822. It is the patient’s/alternatively the guarantor’s responsibility to ensure that he/she understands the approximate costs involved in the care or treatment they will receive by this practice.
- By accepting this form, the patient and/or guarantor acknowledges and confirms that the patient received services through the SHI Telemedicine platform, alternatively that one of the guarantor’s beneficiaries (being your minor child/ren and/or spouse and/or medical aid beneficiary/ies) receiving services in the SHI Telemedicine platform and/or medical attendance.
- The patient and/or guarantor furthermore confirm that he/she/they will be liable for any account rendered to them in respect of the Telemedicine services and/or medical services received.
- S Holt Inc will submit your doctor’s account to your medical aid if you are a valid member.
- S Holt Inc however has no contract with any medical aid or insurer and as such the patient/guardian remains liable for the full account whether the medical aid pays your account, alternatively deny same, and the responsibility is vested in the patient and/or guarantor to ensure that all accounts be settled in full, failing which you/the patient and/or guarantor will be held liable in his/her/their personal capacity as principal debtor of any amount due to S Holt Inc.
- By accepting this form the patient and/or guarantor understands that S Holt Inc shall not be liable directly or indirectly for any loss, damages, costs and/or expenses directly or indirectly sustained by myself/the patient as a result of the services rendered to me through the Telemedicine platform and that I/the patient hold them harmless against all and/or any damages and/or losses incurred by me/the patient as a consequence of any claim arising from the services rendered.
- Failure to pay your account for any reason whatsoever will result in you being handed over to a debt collector whose costs will be borne by you the patient and/or guarantor.
- The patient and/or guarantor agrees to pay all and any costs, fees and/or disbursements incurred by S Holt Inc for the collection of amounts owed by him/her, the patient and/or guarantor which may include tracing costs, debt collector’s fees and commissions as well as attorney fees and disbursements on the scale of attorney and own client.
- S Holt Inc is entitled to charge interest on outstanding accounts over 30 days and will hand over outstanding accounts between 90 and 120 days for collection and upon handover for collections, the patient and/or guarantor responsible for an account being outstanding will be listed with a credit bureau which may affect the patient’s and/or guarantor’s credit profile, in terms of Regulation 19(4) of the National Credit 34 of 2005.
- In the event of legal action being instituted the patient and/or guarantors agree to the jurisdiction of the Magistrates Court in accordance with the Magistrates Courts Act.
- By accepting of this form, the patient and/or guarantor agrees that medical information may be shared with the following:
- Medical aids and/or insurers for the purposes of receiving payment for services rendered by the doctors of S Holt Inc.
- Medical colleagues involved in the treatment of the patient/s and in the rendering of allied medical services.
I acknowledge that I have read and understood this document and accepted the terms and conditions thereof.