Client Consent Form and Contract for Nicole Van Vuuren Physiotherapy
I, the undersigned, grant Van Vuuren Physiotherapy permission to treat myself or legal guardian in her capacity as a physiotherapist. I accept that she does not do assessments or reports for legal purposes.
I, the undersigned, understand that Nicole van Vuuren is a physiotherapist and is registered with the HPCSA. Van Vuuren Physiotherapy will explain the therapeutic process to me and I understand that I have the right to withdraw at any time. I accept that consultations are recorded. I accept that information regarding my therapy may be communicated for referrals and supervision/consultation procedures. My information will remain confidential, however I understand that there are limits to confidentiality, including: should I be a risk to myself or others; when a child is in danger; if the court orders Van Vuuren Physiotherapy to reveal my information. Information can be used for research purposes provided my anonymity is assured.
I understand that Van Vuuren Physiotherapy’s consulting fees are in accordance with the Board of Healthcare Funders of South Africa. I accept that sessions are charged at medical aid rates and are subject to annual increase.
I, the undersigned, accept full responsibility for my account and to settle any outstanding payments. Moreover, I accept full responsibility to ensure that I have received the necessary invoices for sessions that I have attended.
If my invoices are paid at private rates, I understand that it is my responsibility to make payment on the date of the therapy session. Van Vuuren Physiotherapy will make available credit and debit card facilities to make this payment process possible, although a payment via EFT is recommended to the following bank account.
The banking details are as follows:
Bank : First National Bank
Account : van Vuuren Physiotherapy
Branch Name : Promenade Mall
Branch Code : 250655
Type of Account : Current/Cheque Account
Account Number : 62812471324
Reference : Your full name
If my invoices are being submitted to medical aid, I understand that it is my responsibility to liaise with my medical aid regarding payments due and keeping up-to-date with my available funds. You will be notified of any rejection form your scheme. The estimated time to get a payment from the medical aid is 4-6 weeks from the date that the invoice is submitted. With all rights reserved, Van Vuuren Physiotherapy has the option to use legal methods to secure payment; this may include a collection agency or small claims court, in which case the cost of such measures will be added to the claim. Notices of outstanding accounts will be served to your residential, postal and work addresses.
I understand that Nicole van Vuuren may suspend therapy until all outstanding accounts are settled in full.
I understand that if an appointment is not cancelled with 24 hour advance notice I will be charged to me in full. I accept that appointments are taken as confirmed at the time of verbal, Whatsapp, email or sms booking. Any reminders from Van Vuuren Physiotherapy serve as a courtesy and have no bearing on the confirmation of an appointment.
I acknowledge that phone calls and emails that are longer than 10 minutes will be charged for.
Any sessions/consultations with third parties will be charged to the undersigned, even if at the request of Van Vuuren Physiotherapy. With regard to minors, feedback sessions to parents are charged in full.
I understand that that the email address and mobile number provided provided by me below will be used for all correspondence related to my appointments and invoices. Should I not receive the related invoice within 5 working days after a session (those that are attended or missed), I will be responsible for ensuring that I follow-up and ensure that I do have a copy of the related invoice.
I, the undersigned, accept that any late-coming will shorten the length of my session and I will be charged in full. Sessions cannot run overtime if the client is late.
The contract terms in terms can be found lower on this page, for your reference.
Note that the information below with a ‘*’ is mandatory. If you don’t have this information, you can enter a ‘-‘. However, if the information is missing or inaccurate, it will result in a delay of the appointment scheduling, billing process and/ or medical aid follow-up process.
As per outstanding invoices processed by Van Vuuren Physiotherapy
I/We acknowledge that this Authority may be ceded to or assigned to a third party if the agreement is also ceded or assigned to that third party, but in the absence of such assignment of the Agreement, this Authority and Mandate cannot be assigned to any third party.