PATIENT FORM

I, {text-12}, hereby consent to undergo a mammography procedure with Radhiant for the purpose of breast cancer screening and diagnosis.

• I understand that the purpose of mammography is to detect breast abnormalities, including potential cancerous tumors.
• I acknowledge that I have been informed about the potential risks and benefits of the mammography procedure. Risks may include minimal exposure to ionizing radiation. Benefits include early detection of breast cancer.
• I undertake to be liable for all legal costs/fees necessary for the recovery of payment.
• I am aware that if any abnormalities are detected during the mammogram, further diagnostic tests or follow-up procedures may be recommended. I will discuss the results and any necessary actions with my healthcare provider.
• I accept personal responsibility for the payment of the account to the practice whether authorization was granted by my medical aid or not. Pre-authorization does not guarantee payment.
• In case of non-payment, the undersigned accepts the responsibility of payment and interest in collecting the outstanding fees as laid down by the “Health Professions Council of South Africa”.
• I hereby give consent to process my personal information with the provisions of the Personal Information Act, for all purposes related to the carrying out of this mandate.
• I have read and understood the information provided in this declaration form and give my informed consent for the mammography procedure.
• Indemnity: By signing this consent form, I am allowing the practice and any of the third parties, access to my/the patient’s i) confidential personal information ii) medical information. By giving my consent, I hereby indemnify the practice for any consequences arising from the unauthorized access of my/the patient’s reports and/or any of my/the patient’s personal information (as defined in POPIA) and hold the practice harmless against any liability therefrom, to the extent permissible under POPIA, suffered by myself and/or the patient as a result of any of the third parties’ failure to comply with their statutory obligations contained under POPIA and/or any willful and/or negligent acts or omissions of any third party, their employees, contractors, agents or any duly authorized Operators (as defined in POPIA)

NB: ALL PATIENTS WILL BE HELD RESPONSIBLE FOR ACCOUNT UNTIL SETTLED

Important point to note:

1. 1. Please provide your medical aid and ID document on the day of your screening. (Digital copies will be accepted)

1. 1. Patients must be over the age of 40 to qualify for the mammogram benefit on their medical aid.

1. If you have any questions or need assistance, our caring team is just a call or message away.

   We look forward to welcoming you soon!