Consent, account and disclosure terms

I hereby agree to the following: I accept all responsibility for payment of the outstanding amount if not settled by my medical aid within 30 days and for payment of any legal expenses due to non-payment of any accounts on attorney and client scale. I take note that Dr. Madri Verster charges to scale and that I will be responsible for a consultation fee if my medical aid has insufficient funds. I will inform the practice of any changes of my contact details, medical aid or address. I agree that my medical records will be available to all medical practitioners practicing at her practice from time to time. Appointments will be cancelled a minimum of 2 hours prior to the scheduled time of appointment, if not, I will be responsible for the fees involved. I accept that my account will be processed through a third party. I warrant that the above-mentioned information is correct in all aspects and that I will disclose all medical information (surgeries, allergies, chronic medications and illnesses etc. ) that is directly or indirectly relevant to and could have an impact on the effect of the treatment prescribed. The patient agrees that he/she will not hold the practitioner liable for any loss, harm or damage which the patient may suffer pursuant to treatment by the practitioner in cases where there was a failure by the patient to disclose medical information. Furthermore, I indemnify the practitioner against claims of any nature made by third parties which arise out of the treatment of the patient by the practitioner.