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Patient Particulars

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Surname *

Full Names *

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Initials *

Tel no *

Title *

Patient ID Number *

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Occupation *

Age *

Pregnant *

Yes
No
Unsure

Allergies *

Referral Doctor *

General Practitioner *

I hereby give consent for the administration to me of contrast medium and/or drugs which may be necessary or required in order to conduct a radiological examination in respect of my person. I acknowledge and agree that I remain personally responsible for payment of all amounts due to the practice. I agree that it is my duty at all times to ensure that my accounts are paid on due date for payment thereof. I hereby give consent to the practice to disclose my ICD-10 status to my medical aid and any other third party in order to obtain payment of any amount owing by me to the practice. I ackowledge and agree that, should a radiologist not be present at the time my X-rays are taken, I irrevocably undertake to procure a radiologist's report regarding my X-rays from the practice as soon as possible after the X-rays are completed, failing which I agree that the radiologist and the practice shall in no way whatsoever be responsible for any diagnosis made with the use of any such X-rays. I confirm that all the information contained herein is true and correct.

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Upload Signature

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Date *

Name & Surname *

Consent in terms of Section 11(1)(a) of the Protection of Personal Information Act No 4 of 2013

The Protection of Personal Information Act 4 of 2013 (POPIA) protects information personal to individuals and businesses (Data Subjects). The owner of information is the data subject. All other relevant parties are deemed to be processors of personal information. POPIA requires Data Subjects to instruct processors on the obtaining, use, purpose of use and destruction of personal information.

I the undersigned

Name and Surname *

ID Number (Data Subject/Representative of Data Subject) *

Hereby consent to the processing of my personal information by Vaal Radiology Inc. (Operator/Responsible party) for the following purposes:

Advertisements from Operator/Responsible Party
Video surveillance when on premises
Communication from the Operator/Responsible Party regarding the tests/procedures for which I am attending Vaal Radiology
Should I not keep my account up to date to use my information for Legal action.
I Consent that the Responsible Party/Operator may communicate on WhatsApp or any other like forums and via email regarding my case, subject to strict POPIA requirements
Communications and opinions sent from myself to the Operator/Responsible Party may be distributed in their entity for the purpose of effective functioning of their business and to deliver the services for which I have contracted with them.
Destruction of any and all personal information held by the Responsible Party after 7 years, without prior written notice to myself.
Any urgent reasonable action needed on an urgent basis by the Operator/Responsible Party.
To send accounts for my attention and payment
To give any information/data pertaining to my case to any medical professional, ambulance, specialists, hospitals, medical aids, my emergency contact and any other persons the Responsible Party deems necessary for case specific results.
To use my medical information for census/medical journal/medical date capturing/statistical purposes.
That my files and information may be transported between the practice and offices of Vaal Radiology