Patient forms, consent documents and fee guide.

PATIENT FULL NAME ID / PASSPORT NUMBER

DATE OF BIRTH MOBILE NUMBER

EMAIL ADDRESS MEDICAL SCHEME

SCHEME MEMBERSHIP NUMBER MAIN MEMBER

Dr Tembisa Tini Inc collects and maintains personal information and medical records to provide healthcare, manage appointments and accounts, obtain relevant investigations and referrals, administer medical-scheme claims and meet applicable legal and professional requirements. This may include sensitive reproductive, obstetric and gynaecological information. Your information is treated as confidential. The practice will use appropriate safeguards and limit access to authorised persons who require the information for a legitimate purpose. Records are maintained and retained as required by applicable health, privacy and professional rules. Where appropriate, relevant clinical information, including ICD-10 diagnosis codes, may be shared with healthcare professionals, laboratories, hospitals, medical schemes or other authorised parties involved in your care or payment for that care. Disclosures outside these purposes require an appropriate lawful basis and, where applicable, your consent.

The practice may send accounts, statements, receipts, quotations, authorisation documents and administrative notifications through the contact details provided by you. Clinical results and other sensitive communications may be sent electronically only where you have chosen that communication method or another lawful basis applies. Certain results may require a consultation or direct discussion. Please inform the practice promptly if your contact details change. Electronic communication can carry privacy risks if an email account or device is shared or accessed by another person.

Where hospitalisation or a procedure is required, you remain responsible for confirming your medical-scheme benefits, obtaining any required pre-authorisation and arranging payment of amounts not covered by your scheme. The practice will provide reasonable supporting documentation, including quotations where applicable, to assist with this process. Pre-authorisation is not a guarantee of payment.

Consultations and procedures performed in the rooms are payable in full on the day of service unless another arrangement has been agreed in writing. Available payment methods may include card, cash and electronic funds transfer. Telephonic consultations, repeat prescriptions, authorisations, motivations and medical reports may be billable services. You remain responsible for fees not settled by your medical scheme and any lawful recovery costs on overdue accounts.

Purpose. With your separate consent, the practice may use a listening or dictation device and a secure digital transcription service to capture spoken information during your consultation and convert it into a draft written clinical note. This assists with accurate records, referrals and reports, and allows the clinician to give greater attention to your consultation. Clinical responsibility. The transcription output is a documentation aid only. Your treating clinician remains responsible for checking, correcting and approving clinical notes before they become part of your medical record. Clinical decisions are made by your clinician. Privacy and service providers. Spoken information may include sensitive medical information. An external transcription service provider may process this information on the practice's behalf under appropriate confidentiality and security arrangements. Information about the current service provider, any applicable processing outside South Africa and relevant retention arrangements is available from the practice before you consent. Audio processing and retention. Audio may be captured and temporarily processed to prepare written documentation. Consent to transcription does not, by itself, authorise the practice to keep a separate long-term audio recording. If audio is to be retained beyond what is required for transcription, the practice will explain the purpose and retention arrangements and seek separate consent where required. Your choice. Digital transcription is voluntary. You may decline it, ask that it be stopped, or change your choice for future consultations. The clinician will use another method of documentation. Any records already lawfully created remain subject to applicable recordkeeping requirements.

Clinical photographs or video may be used where clinically appropriate only in accordance with your choice and applicable law. Identifiable use for teaching, publication, presentations or research requires a separate assessment and consent where required. Permission to contact you about future research is an independent, optional choice and does not constitute agreement to participate. If a partner, family member, interpreter or another person is present during a consultation, please inform the clinician if you have concerns about the capture of that person's speech or your privacy. The clinician may pause transcription or take other appropriate measures.

Please tick ONE choice in each row. An unanswered question is not treated as consent.

CONSENT ITEM YES NO

Electronic clinical communications I agree to receive suitable clinical results and communications at the electronic contact details I have ☐ ☐ provided.

Medical reports I authorise the practice, where clinically appropriate, to request medical reports relevant to my ☐ ☐ condition or care.

Medical scheme / diagnostic information I consent to relevant clinical and diagnostic information, including ICD-10 codes, being supplied to my ☐ ☐ medical scheme and, where applicable, the principal member for claims administration.

Clinical photography / video I consent to clinically appropriate photographs or video being recorded for my medical record. Other ☐ ☐ uses require separate consideration and consent.

Future research contact I agree to be contacted about possible future practice research or service-evaluation activities. ☐ ☐ Participation remains voluntary.

Digital medical transcription I consent to my consultation speech being captured and processed for digital transcription to assist in ☐ ☐ preparing clinical documentation, as explained in section 6.

Subject to lawful disclosures, list any individuals to whom you do not wish the practice to disclose your information: [complete in the PDF]

☐ I confirm that the information supplied is accurate; that the practice terms have been explained or made available to me; and that I understand my fee obligations, privacy rights and individual choices above. Where a patient requires a representative, the practice must confirm legal authority to consent. A minor who may consent independently under applicable law should not be required to obtain a parent's signature solely because of age. PATIENT / AUTHORISED REPRESENTATIVE NAME RELATIONSHIP TO PATIENT (IF APPLICABLE)

PATIENT / REPRESENTATIVE SIGNATURE DATE AND PLACE SIGNED

PRACTICE REPRESENTATIVE / CLINICIAN DATE

FULL NAME ID / PASSPORT NO.

[complete in the PDF] [complete in the PDF]

ESTIMATED DUE DATE CURRENT GESTATION

[complete in the PDF] [complete in the PDF]

MEDICAL SCHEME MEDICAL SCHEME NO.

[complete in the PDF] [complete in the PDF]

MOBILE NUMBER EMAIL ADDRESS

[complete in the PDF] [complete in the PDF]

This document records the practice terms that apply to pregnancy-related consultations, antenatal care, delivery planning and associated services provided by Dr Tembisa Tini Inc. It is intended to make the practice arrangements, financial responsibilities and communication expectations clear before care proceeds.

Important: Clinical care is always guided by the circumstances at the time. Nothing in this form limits a patient's right to ask questions, seek a second opinion, request referral or receive appropriate emergency care.

 Practice fees may be reviewed from time to time, including annually. Current consultation, delivery and procedure fees should be confirmed with the practice. A written quotation for a specific planned procedure or service will apply according to its stated terms.  You remain responsible for the account for services provided to you, including consultations, pregnancy care, deliveries and procedures, regardless of the amount reimbursed by your medical scheme or insurer.  If your medical scheme or insurer delays, rejects or only partially pays a claim, you remain responsible for any amount lawfully due to the practice. Any overdue-account interest, administration or collection charges will be applied only in accordance with the practice billing policy and applicable law.  If you are a dependant on a medical scheme, you should ensure that the principal member is aware of the expected costs and any financial arrangements relating to your care.

Medical-scheme membership does not guarantee full payment of the practice account. You are responsible for confirming your available maternity benefits, network requirements, co-payments and exclusions, and for obtaining any required hospital or procedure pre-authorisation. The practice will provide reasonable supporting information, quotations and clinical codes where appropriate to assist with this process.

The practice will advise you of the hospital or facility arrangements applicable to your planned delivery and of any relevant admission requirements. Delivery plans may need to change for clinical, operational or emergency reasons.

Dr Tembisa Tini may not always be personally available for every consultation, labour, delivery or emergency. Where necessary, a suitably qualified covering or locum doctor may provide care. This may include a male doctor. Where practicable, the practice will explain the covering arrangement, but emergency care will not be delayed when immediate clinical attention is required.

Your consultations and pregnancy-related care are recorded in your clinical record, which may be stored electronically. Personal and health information is treated as confidential and processed for healthcare, administration, billing and other lawful practice purposes.

Relevant information may be shared with healthcare professionals involved in your care, hospitals, laboratories, radiology providers, medical schemes or insurers where necessary for treatment, referral, authorisation or claims administration. This may include the use of ICD-10 and procedure codes.

Routine administrative and clinical communications should use the channels provided by the practice. SMS, WhatsApp, email and website messaging should not be relied on for urgent or emergency medical care unless the practice has specifically designated a channel for that purpose.

For urgent pregnancy concerns or an emergency: use the emergency contact process provided by the practice or attend the appropriate emergency / maternity unit. Do not wait for a reply to a routine electronic message.

Please initial each item after reading it. If you do not understand or agree with an item, discuss it with the practice before signing.

ACKNOWLEDGEMENT INITIALS

Fees and account I understand that I am responsible for fees charged for care [complete in the PDF] provided to me, including amounts not paid by my medical scheme or insurer.

Medical-scheme benefits I understand that I must confirm my maternity benefits, [complete in the PDF] network rules, co-payments and pre-authorisation requirements with my medical scheme.

Covering doctors [complete in the PDF] I understand that a covering or locum doctor may provide care

ACKNOWLEDGEMENT INITIALS

when Dr Tembisa Tini is unavailable, including during labour, delivery or an emergency.

Hospital / facility arrangements I understand that the practice will advise me of the applicable [complete in the PDF] delivery facility arrangements and that these may change if clinically or operationally necessary.

Privacy and records I understand that my health information will be recorded and [complete in the PDF] processed for my care and lawful practice administration.

Information sharing I consent to relevant clinical information being shared with [complete in the PDF] healthcare providers and authorised parties involved in my care, authorisation or claims administration.

Electronic communication I understand that routine electronic communication is not an [complete in the PDF] emergency service and I must use the designated emergency process for urgent concerns.

Choice of care I confirm that I have chosen to receive care from this practice [complete in the PDF] voluntarily and understand that I may ask questions, seek a second opinion or request a referral.

Record any agreed special arrangement, exception or clarification here. Any financial or practice-policy exception should be confirmed in writing by an authorised practice representative.

[complete in the PDF]

[complete in the PDF]

By signing below, I confirm that I have read and understood this form, have had an opportunity to ask questions, and accept the practice arrangements described above. I confirm that the information I have supplied is true and correct to the best of my knowledge.

PATIENT NAME ID / PASSPORT NO.

[complete in the PDF] [complete in the PDF]

PATIENT SIGNATURE DATE

[complete in the PDF] [complete in the PDF]