Email Address
Name and Surname of patient
Tel Number
Id number
Type of Procedure
Name of surgeon
Date of surgery
Hospital where surgery is planned
Date of admission pre-operatively
Medical aid
Medical aid option
Medical aid number
Gender, age, weight and height?
Previous surgeries and dates. Problems with previous anaesthesia. Give details
Any family members with previous anaesthetic complications
Any allergies or unusual reactions to medication.
List your current chronic medication including any supplements.
Are you Injecting drugs for weight loss/Diabetes?
Do you take any illicit substances or performance enhancing agents?
Did you take cortisone therapy in the preceding 12 months. Type, dose and duration.
Do you have any heart conditions? (Heart attack, chest pain rheumatic fever ect)
Do you have high blood pressure?
Do you have any lung or respiratory conditions? ( Asthma, Bronchitis, Emphysema, or chronic sinusitis ect.)
Do you currently have or did you have a cold or flu in the previous 4 weeks? Diabetes?
Thyroid problems
Jaundice, hepatitis or liver disease?
Kidney or bladder conditions?
Any Muscle disorders, muscle weakness, paralysis or stroke?
Tendency to bleed or bruise easily?
Previous or current blood clots ot thrombosis. Specify where and when.
Epilepsy, loss of consciousness or spells of fainting (black outs)?
Do you or any direct family members have porphyria?
Do you or any direct family members have malignant hyperthermia or Scoline apnoea?
Any dentures, loose teeth or crowns? If so, where?
Is it possible that you might be pregnant? If so, how far are you?
Do you smoke? If so, how much and for how long?
How many units of alcohol do you consume per week? (One unit is a beer, a glass of wine or a measure of spirits?
Is there anything else that your anaesthetist should know about your health or planned procedure?
2. I understand that during the procedure, my physical and surgical conditions may alter and require changes in the management of my anaesthesia. This will be done with my safety as first consideration.
3. I understand that the transfusion of blood and/or other blood products may be required during the procedure
4. I understand that an incident-free anaesthetic cannot be guaranteed.
5. I understand that anaesthetic support staff and equipment are supplied by the hospital and cannot be guaranteed by the anaesthesiologist. Equipment is checked on a daily basis.
6. I understand that no guarantee can be given regarding my response to drugs administered during the anaesthetic.
7. I understand that receiving anaesthesia will have certain risks. Risks and complications may include, but is not limited
General Anaesthesia: Sore throat, hoarseness, injury to airway and teeth, nausea and vomiting, pneumonia and other lung problems, injury to nerves and blood vessels, adverse drug reactions, awareness under anaesthesia, brain damage and loss of life.
Regional anaesthesia and spinal/epidural: As for general anaesthesia as well as low blood pressure, headache, minor pain and discomfort during the procedure, residual weakness and loss of sensation, infection, failed technique and conversion to general anaesthesia.
2. I accept full responsibility for the full amount of the anaesthetic account.
3. I understand that the anaesthesia account will be billed at the standard tariff of Skoltramed anaesthesiologist and may be more or less than my medical scheme rate. Insert link to billing policy
4. I have read the billing policy of Skoltramed Anaesthesiologists and understand that it is my responsibility to contact the practice ahead of surgery for a detailed cost estimate.
5. I understand that EFT payments must be accompanied by the correct reference number, and that the anaesthesiologist will not be held responsible for any costs associated with payments that could not be allocated due to incorrect reference numbers.
6. I declare that the anaesthetic account will not form part of any administrative orders that exist on the guarantor’s name.
7. I declare that all personal information supplied by me is true and correct. (Domicilium citandi et executandi.)
Accept above mentioned
Decline above mentioned
8. I agree to allow my personal data and health information to be collected in terms of consent to be utilised for healthcare of the patient, billing and debt collection as well as processing of queries, complaints and/or compliments; as required by the POPI Act.
9. I agree for my information to be shared with relevant organisations as part of a legitimate process within the ordinary course and scope of this practice, provided such disclosures are in the best interest of both parties.
10. I understand that my personal information is stored in a secure location and is accessible only to authorised third parties who are certified to be compliant with the POPI Act.
Accept above mentioned
Decline above mentioned
11. I accept responsibility for all legal and tracing costs that may be incurred due to non-payment according to attorney and client scales.
12. I declare that if I am not the guarantor, I have permission of the guarantor to sign this contract
13. I declare that I have read and understand the complete contents of this document and that I accept all terms and conditions as specified in the “Payment Terms”
13. I declare that I have read and understand the complete contents of this document and that I accept all terms and conditions as specified in the “Payment Terms”
Accept above mentioned
Decline above mentioned
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