Impressum
In this consent contract, ‘I’ refers to Naazneen Khan, practicing as MYDIETITIAN. PR number 8411557, HPCSA registration number DT 0017736.
1st session
In order for me to render a service to you (and/or your child), I need to do a proper evaluation to gain understanding of your medical history, mental and social readiness and also current eating practices. This session is exploratory, where I will ask you a number of pertinent questions about yourself, your family (and/or your child). After the evaluation we will discuss my findings and decide on a future plan of action.
Follow up sessions
These 30 min sessions are meant to track progress on the agreed plan of action, and may/may not include change in the intervention. This totally depends on your adaptability, your symptoms, and your commitment.
Purpose of MYDIETITIAN’s approach
The purpose of my intervention is to elicit change. This could have some unfamiliar responses, and may lead to initial anxiety or even the thoughts of giving up. The cornerstone of your success is the degree to which you take responsibility to bring about change. I cannot guarantee any specific outcome, as the process is meant to empower you with the tools to eventually practice sustainable and healthy eating practices, to best alleviate your challenges.
Confidentiality
I am bound to treat all the private information I collect about you/your child/your family as highly confidential. I will not, subject to what is stated below, disclose any information about you without your consent. In certain exceptional situations, however, legal or professional rules may force me to disclose information about you.
This will include:
* Emergency situations: should a situation develop where you/MYDIETITIAN/any other person be in danger or at risk, I will, without hesitation, take the necessary steps to prevent such harm, even if this may entail my breaching my promise to you to keep information confidential.
* Statutory duty: A provision in an Act may oblige me to disclose confidential information about you/your child/your family.
* Court orders: A court may order me to disclose private information. In terms of my professional rules I must, however, endeavour to do everything possible to prevent the disclosure of your private information.
* That which I have pointed out above is also applicable in respect of children under the age of 18.
* Subject to what is stated about confidentiality, I will not issue a report to any medical professional without your consent.
Fees
* Dietetic and Nutrition intervention tariffs within the Republic of South Africa (RSA) vary according to different medical schemes. Please make sure you are familiar with your specific Scheme/Provider tariffs, and also whether they will reimburse you for your sessions with MYDIETITIAN. MYDIETITIAN will not submit claims to any medical aid, but will gladly issue you with documents for you to claim back from your Provider.
* The cash rate of this practice is subject to change without prior notification. Consultation fees are payable at the beginning of each individual consultation (unless otherwise agreed upon).
* Cash payment can be made via EFT bank payment or through the credit card facilities available for your convenience. Please enquire regarding the updated rate.
* There is a difference in the telehealth rate for the 1st session due to the fact that MYDIETITIAN will not be able to perform any body composition measurements.
* Telephone calls lasting longer than 10 minutes will be billed as a follow up (30min consult) to the patients account.
* MYDIETITIAN reserved the right to bill you in full for sessions not cancelled 24 hours in advance.
* Any sessions going over the allocated time, will be billed for as a 30-minute consultation.
Your Informed consent (CONTRACT)
I also bind myself by contract with regard to the following:
I, therefore hereby grant permission to MYDIETITIAN to obtain information from or provide it to authorised persons and parties as agreed upon, if this is regarded to be in the interest of my child, my family or myself.
I fully accept that MYDIETITIAN cannot guarantee the outcomes of my program, as I am fully responsible for the decisions I make, and MYDIETITIAN will not be held liable for my success.
The tools MYDIETITIAN provides, such as advice, homework, recipes, etc. are meant to assist me in the intervention with the outlook of long term goals.
I undertake to settle the account by EFT or using credit card facilities provided for regardless of the platform used to conduct the session, before the session. If any fees are outstanding after 30 days and arrangement for payment has not been agreed upon, then legal action may be taken against me for the settlement of the account, all the ensuring costs will be my responsibility. I further agree that a full consultation fee (60 minutes) may be charged to my account (or then claimed from my medical aid) for appointments not cancelled at least 24 hours in advance.
I understand there may be potential risks to using telehealth methods, including interruptions, unauthorised access risks and technical difficulties. I also agree not to record any sessions or part thereof as per the POPI Act of South Africa.
Disclaimer
By making a booking with MYDIETITIAN, on any platform, I indicate that I have reviewed, understand and agree to comply with the policies/statements in this agreement and that I consent to dietetic and nutrition intervention for myself/my child/my family. I accept responsibility of all the above and will not at any time hold Naazneen Khan/MYDIETITIAN liable for any costs (including legal proceedings), or other.