Patient Information


POPI CONSENT FORM

 

    1. I hereby grant my consent to Dr Glen Vardi and his appointed processor to process my personal data for the purpose of any or all of the undermentioned actions, being the legitimate reason for processing and/or using my personal date.

    2. I accept that my personal information will only be utilized for the purpose it was collected, that the information will only be retained for as long as is necessary and required by law, and that I have the right to view such information at that time, as well as request correction or deletion of my personal information held by the Practice.

    3. I am aware that I may withdraw my consent at any time by using the relevant Data Subject Consent Withdrawal Form.

    4. I herewith consent to Dr Glen Vardi collecting and having access to my personal information.

    5. I expressly consent to Dr Glen Vardi collecting and processing this information for the purpose of rendering services to me as well as processing claims with my medical aid.

    6. I expressly consent to Dr Glen Vardi handing over any outstanding accounts to debt collection third parties.

    7. I expressly consent to Dr Glen Vardi and his administrative staff having access to my personal information contained in my health record, including any clinical notes to process claims to my medical aid, issuing documentation or any other administrative function required by my health care practitioner.

    8. I expressly consent to the Dr Glen Vardi using my personal information to communicate with me in person via telephone, email, video call, WhatsApp or any form of social media.

    9. I expressly consent that the Management Group/Society to which Dr Glen Vardi belongs be provided with such of my personal health information to enable them to render certain administrative services including coding queries, billing issues and audit assistance.

    10. 10. I express consent that Dr Glen Vardi may discuss any of my personal health information with any of the other members of the clinical team that may at any stage of my treatment be involved in providing health care services to me and to forward any such information to the referring health care practitioner.

    Signed

    Date

    DR GLEN VARDI STRIVES TO RESTORE MOBILITY OF THE KNEE.