Patient Registration
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Personal Details
Medical Aid (if applicable)
Informed Consent
I, the undersigned patient (or authorised representative), hereby consent to wound care assessment and treatment by Antonet Brand, Private Nurse Practitioner, trading as Aspigon 209 (Practice No. 0998354).
I understand that services provided include wound assessment, dressing changes, wound debridement where clinically indicated, and related nursing care. Treatment is conducted at my home or agreed location.
I consent to clinical photographs being taken of my wound(s) solely for the purpose of monitoring healing progress and maintaining clinical records. Photos are stored securely and will not be shared beyond my direct care team without my written permission.
I acknowledge and agree that Aspigon 209 T/A Antonet Brand does not submit claims directly to any medical aid scheme. All fees are payable in full by me on receipt of invoice or immediately after each consultation/treatment session. It is my sole responsibility to submit claims to my medical aid for reimbursement.
I understand that on request, the practice will supply all required supporting documentation for my medical aid claim, including clinical motivation letters, treatment summaries, and assessment reports.
I agree to provide at least 24 hours' notice for cancellation or rescheduling of appointments. Late cancellations or no-shows may be subject to a call-out fee.
My personal and clinical information is held in confidence in accordance with the Protection of Personal Information Act (POPIA) and applicable health legislation. Information will not be disclosed to third parties without my consent except where required by law.
I understand that any patient care, treatment or clinical procedure performed within the practitioner's scope of practice carries inherent risks. These include infection, bleeding, bruising, allergic or adverse reactions, pain, discomfort, delayed healing, scarring and other complications. These risks can arise even when care is provided correctly and with reasonable professional skill. I accept that the outcome depends on many factors outside the practitioner's control, such as my general health, existing medical conditions, medication, nutrition, smoking and whether I follow the care instructions I am given.
I understand that no specific result, recovery time or outcome has been promised or guaranteed to me.
To the extent permitted by law, I agree that Antonet Brand, the practice and Aspigon 209 will not be held liable for any injury, loss or complication arising from patient care performed with reasonable care and skill. This also covers any harm resulting from my failure to follow instructions, attend appointments or give complete and accurate medical information.
This limitation does not apply to any loss caused by gross negligence or wilful misconduct, or where the law does not allow liability to be limited.
I confirm that I have read and understood this consent, that I am providing consent voluntarily, and that I have had the opportunity to ask questions before signing.
I, the undersigned patient (or authorised representative), hereby consent to wound care assessment and treatment by Antonet Brand, Private Nurse Practitioner, trading as Aspigon 209 (Practice No. 0998354).
I understand that services provided include wound assessment, dressing changes, wound debridement where clinically indicated, and related nursing care. Treatment is conducted at my home or agreed location.
I consent to clinical photographs being taken of my wound(s) solely for the purpose of monitoring healing progress and maintaining clinical records. Photos are stored securely and will not be shared beyond my direct care team without my written permission.
I acknowledge and agree that Aspigon 209 T/A Antonet Brand does not submit claims directly to any medical aid scheme. All fees are payable in full by me on receipt of invoice or immediately after each consultation/treatment session. It is my sole responsibility to submit claims to my medical aid for reimbursement.
I understand that on request, the practice will supply all required supporting documentation for my medical aid claim, including clinical motivation letters, treatment summaries, and assessment reports.
I agree to provide at least 24 hours' notice for cancellation or rescheduling of appointments. Late cancellations or no-shows may be subject to a call-out fee.
My personal and clinical information is held in confidence in accordance with the Protection of Personal Information Act (POPIA) and applicable health legislation. Information will not be disclosed to third parties without my consent except where required by law.
I understand that any patient care, treatment or clinical procedure performed within the practitioner's scope of practice carries inherent risks. These include infection, bleeding, bruising, allergic or adverse reactions, pain, discomfort, delayed healing, scarring and other complications. These risks can arise even when care is provided correctly and with reasonable professional skill. I accept that the outcome depends on many factors outside the practitioner's control, such as my general health, existing medical conditions, medication, nutrition, smoking and whether I follow the care instructions I am given.
I understand that no specific result, recovery time or outcome has been promised or guaranteed to me.
To the extent permitted by law, I agree that Antonet Brand, the practice and Aspigon 209 will not be held liable for any injury, loss or complication arising from patient care performed with reasonable care and skill. This also covers any harm resulting from my failure to follow instructions, attend appointments or give complete and accurate medical information.
This limitation does not apply to any loss caused by gross negligence or wilful misconduct, or where the law does not allow liability to be limited.
I confirm that I have read and understood this consent, that I am providing consent voluntarily, and that I have had the opportunity to ask questions before signing.
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