INFORMED CONSENT TO CHIROPRACTIC TREATMENT AND GENERAL INDEMNITY

I hereby request and consent to the performance of chiropractic treatment (or on the patient named below, for whom I am legally responsible) by the chiropractor and/or anyone registered as a chiropractor working in this office authorized by same. I further understand that such chiropractic services may be performed by the chiropractor and/or registered practitioner of chiropractic who may treat me now or in the future at this office.

 

I am further aware and consent that in order to proceed with an effective treatment, my health status must be evaluated by means of an interview and/or the performance of clinical tests. The reason for this is to diagnose my condition but also to determine any contraindication I may have to any recommended treatment. I am further aware of my right to have a person of my choosing present during certain physical examinations and my right not to remain disrobed any longer than is required for accomplishing the examination.

 

I understand that, as with any health procedure, there are certain risks that may arise during chiropractic treatment. The risks associated with joint manipulation and mobilization are typically minor if they occur, possible side effects include mild to moderate discomfort, autonomic phenomena such as dizziness, headaches and post treatment discomfort. More severe complications are extremely rare but have been reported, such as fractures, dislocations, disc herniation or progression of neurological symptoms and stroke. Other chiropractic treatments that this practice may utilize are dry needling therapy, electrotherapy, temperature therapy, soft tissue therapy, strapping and bracing. Risks associated with these therapies include bleeding, bruising, infection, lung puncture, pain, autonomic phenomenon such as dizziness and nausea, burns, electrocution, skin irritation and discomfort.

 

Should I experience any side effects, I confirm that I will immediately notify my chiropractor and inform him of same. My failure to raise any concern will create the assumption that I am satisfied with the service provided and further indicates that I am not experiencing any side effects to the treatment provided.

 

I acknowledge that I have read this consent and I have discussed, or have been offered the opportunity to discuss, with my chiropractor the nature and purpose of chiropractic treatment in general, the treatment options and recommendations for my condition, costs and the contents of this consent. I also understand that results are not guaranteed.

 

I intend for this consent to apply to my present treatments and, in future, should it occur that my condition changes during the course of my treatment, I will participate in any decision affecting my personal health and course of treatment. I further note my right to withdraw my consent at any time for any specific procedure and/or treatment.

 

I understand my chiropractor’s legal duty and herewith consent to the disclosure of my diagnosis to the medical schemes, other medical professionals and support staff in the employ of this practice for purposes of reimbursement and/or settlement of my account, administrative tasks and/or referral. I also hereby accept full financial responsibility for this account until it is settled in full. I confirm that all details provided are both true and correct. It has further been explained to me the costs involved in chiropractic treatment and agree to said costs. I also understand that should I not cancel an appointment within twenty four (24) hours of said appointment I may be invoiced for the full amount.

 

I further understand that access to the premises of the chiropractor and the use of all facilities is done at my own risk. Neither the owner of the premises nor the chiropractor who operates the business or their employees, agents or anyone temporarily in their service shall be liable for any damage, loss and/or injuries sustained as a result of such entry unto the premises and I hereby indemnify the owner of the premises, the chiropractor/s and all employees in their service, agents and/or temporary workers against any liability for loss or damage of any kind whatsoever.

 

Any video recordings or photography of treatments/manipulations are prohibited unless expressly permitted by the Chiropractor and for private use only. Such recordings and videography may under no circumstances be shared or distributed in any way or form on any public platform, be it social media or WhatsApp group or any other public domain or area where more than one person will have access to such video or photograph. Any such actions will be in contravention of the rules of the AHPCSA and will breach practitioner and patient confidentiality.

 

INFORMED CONSENT TO THE RELEASE OF PERSONAL AND MEDICAL INFORMATION

 

I understand my chiropractor’s legal duty and herewith consent to the disclosure of my diagnosis (ICD-10 codes) to the medical schemes for purposes of reimbursement and/or settlement of my account. I further understand that this disclosure has consequences and same has been explained to me.

 

I acknowledge that once my information has been sent to the relevant medical scheme, Dr Jacques H Maree Chiropractor has no further control over the management and utilisation of the information and understand that the medical scheme will take responsibility for any further disclosure or utilization of such information for whatever purpose.

 

I further understand and consent to the disclosure of my medical information to other chiropractors and support staff in the employ of Dr Jacques H Maree Chiropractor. It has been explained to me that each member of the staff has signed a confidentiality agreement which ensures that they are not able to disclose my personal and medical information to any third party, family member etc. of the respective employee.

 

Dr Jacques H Maree Chiropractor will not disclose any personal and medical information to any of my friends or family members unless express consent is given by me, authorising them to disclose certain information to same.

 

I have the right to withhold my consent to the disclosure of my personal and medical information and understand that same will result in me having to reimburse and settle the account directly with Dr Jacques H Maree Chiropractor.

 

I intend for this consent to apply to my present treatment and, in future, should it occur that my condition changes during the course of my treatment, I will sign a new informed consent form to give effect to said decision.

 

I indemnify Dr Jacques H Maree Chiropractor from any liability, damages or whatsoever that I may suffer as a result of this disclosure and that I will hold this practice and its staff harmless of any further disclosures and prejudice I may suffer as a result of such disclosures.

​

INFORMED CONSENT TO THE FINANCIAL RESPONSIBILITY OF MY ACCOUNT

 

I, hereby accept full financial responsibility for this account until it is settled in full. I confirm that all details provided are both true and correct. It has further been explained to me the costs involved in chiropractic treatment and agree to said costs.

 

I understand that should I not cancel an appointment within twenty four (24) hours of said appointment I will be invoiced for the full amount.

 

Accounts will be rendered electronically and it is my duty to ensure that all information is correct. Should information be incorrect I will ensure that I notify Dr Jacques H Maree Chiropractor within a reasonable time. I further am responsible to rectify/clarify and mistakes/errors made by the medical aid with the medical aid directly, Dr Jacques H Maree Chiropractor will not be liable/responsible for said mistakes/errors.

 

In the event of an injury on duty, it is my responsibility to submit the necessary documentation within ten (10) days after the starting date of the treatment. Should I fail to submit same, I will become liable for the full amount.

 

Should I not effect payment of any outstanding invoice, Dr Jacques H Maree Chiropractor will proceed as follows:

1. A follow up telephone call, sms or e-mail will be sent should the account not be paid within thirty (30) days;

2. A final written warning will be sent via e-mail to my personal e-mail address should the account not be paid within sixty (60) days;

3. Should I not settle the invoice after receipt of the final written warning, the account will be handed over to attorneys for further legal action;

4. I acknowledge that as a result of my failure to pay the account, I will be liable for all legal fees, on an attorney client scale, incurred in the collection of the outstanding account.

 

I herewith confirm the aforementioned and further that all costs implications have been discussed with me.

​

WITHDRAWAL OF CONSENT

 

I understand that it is my right to withdraw consent or refuse care at any time or for any specific procedure. I further confirm that in doing so there are, or might be, implications, risks and obligations for my health. The chiropractor has explained such implications, risks and obligations to me.

 

The full informed consent document is also available here to download.

The full informed consent document regarding Treatment of Minors is also available here to download.

​

​

INFORMED CONSENT FOR THE EXAMINATION AND TREATMENT OF A MINOR

 

1. Purpose and Scope 

​

Entering into a therapeutic relationship creates duties and responsibilities for both the practitioner and the parent/guardian. This consent form explains the nature and expected benefits of the treatments offered by the Practitioner, the potential risks and alternatives, and the rights and responsibilities of the child and the parent or guardian. It serves as the basis of the therapeutic contract between the practitioner and the patient. The practice complies with the National Health Act 61 of 2003, Allied Health Professions Act 63 of 1982, Children’s Act 38 of 2005, Protection of Personal Information Act (POPIA) and the Regulation of Interception of Communications and Provision of Communication-related Information Act 70 of 2002. The consent process is ongoing, and the parent/guardian is encouraged to ask questions at any time. 

​

2. Child’s Rights 

​

1. Right to Confidentiality and Dignity: The child’s personal information and dignity will be respected. All medical records are kept confidential and will only be released with proper authorisation or as required by law. The child will not be kept partially undressed or otherwise for longer than is necessary for examination or treatment, and they are entitled to a chaperone during examinations. If a competent child requests that certain information not be shared with a parent or guardian, the practitioner will respect this request unless disclosure is essential for the child’s welfare or required by law. In such cases, the practitioner will discuss the need for disclosure with the child before sharing the information. 
    

2. Participation in Decisions: Children who are capable of understanding have the right to participate in decisions regarding their care. The practitioner will engage the child in a manner appropriate to their level of understanding. Minors aged 12 years or older and of sufficient maturity may consent to their own medical treatment. 
    

3. Access to Records: Children aged 12 years or older can access their own health records on request. For children under 16 years, parents or legal guardians may apply for access to the records, but access should only be granted if the child provides written authorisation. Parental access may be withheld when disclosure would not be in the child’s best interests, violate another law, or pose a serious threat to the child’s safety or to public health. 
    

4. Freedom to Refuse Treatment: The child (if of sufficient maturity) or the parent/guardian may refuse any proposed treatment or withdraw consent at any time without prejudice to future care. Consent is voluntary and can be withdrawn orally or in writing. 

5. Right to Refuse Recording: The child and parent/guardian have the right to decline any audio or video recording of consultations. No recording will take place without the express, mutual consent of the practitioner and the parent/guardian. 
    

3. Parent/Guardian Rights and Responsibilities 
 

1. Right to Information and Questions: The parent/guardian has the right to receive a clear explanation of the child’s condition, proposed treatments, expected benefits, potential risks and alternatives. Questions are encouraged at any time; the practitioner will endeavour to answer fully and honestly. This right is balanced with the child’s confidentiality; where a competent child requests that certain information remain private, the practitioner may limit disclosure to protect the child’s wellbeing unless disclosure is necessary for the child’s best interests or legally required.
    

2. Right to Restrict Disclosure: Parents or legal guardians may restrict how their child’s personal health information is used and may limit its sharing with other healthcare providers or third parties. These restrictions must be put in writing and may affect treatment options. 
    

3. Right to Second Opinions and Referrals: The parent/guardian may seek a second opinion or request referral to another healthcare provider at any time. 
    

4. Right to Request Telehealth: Telehealth consultations may be offered when appropriate, and the parent/guardian may request an in-person consultation instead of telehealth. Messaging applications such as WhatsApp will only be used for administrative communications (e.g., scheduling appointments and reminders); sensitive clinical information will not be shared via these platforms. 
    

5. Right to Record Consultations: Under the Regulation of Interception of Communications Act, parents may request to record consultations for personal records. The parent/guardian must inform the practitioner before any recording takes place. Recording is only permitted when both the practitioner and the parent/guardian agree, and such agreement must be documented. Unauthorized recordings are not permitted. 
    

6. Duty to Provide Complete Information: The parent/guardian must disclose all health-related information about the child, including symptoms, injuries, medications, allergies and previous treatments, as accurate information is essential for safe and effective care. 
    

7. Duty to Review Supplementary Information: Where practical, digital links to detailed explanations of the child’s condition and proposed treatments will be provided, and the parent/guardian is responsible for accessing and understanding these materials. 
    

8. Duty to Report Side Effects: If the child experiences any adverse reactions or side effects following treatment, the parent/guardian must inform the practitioner promptly. Failure to report side effects may be taken as confirmation that the treatment outcome was satisfactory. 
    

9. Financial Responsibility: I acknowledge that I am personally responsible for the payment of allprofessional fees, products, and related costs arising from my child’s assessment and treatment. Where applicable, medical aid or insurance claims will be submitted as a courtesy; however, I remain responsible for any co-payments, shortfalls, items not covered by the scheme, or any amounts rejected by the medical aid. All accounts are payable on presentation, and outstanding balances may attract collection costs if not settled within the agreed period.  
    

4. Consent and Treatment 
 

1. General Consent: Signing this form authorises the practitioner to conduct a clinical examination and provide appropriate treatment. The practitioner may perform case-appropriate tests, including physical examination, range-of-motion assessment, postural analysis and orthopaedic or neurological tests. Prior to any specific procedure, a detailed explanation of that procedure will be provided, and separate consent will be obtained. 
    

2. Therapeutic Approaches: Treatment may include, but is not limited to, manual therapy (such as chiropractic adjustments or joint mobilisation), soft tissue techniques (such as massage), dry needling (when age appropriate), electrotherapy modalities (e.g., ultrasound or interferential current), remedial exercises, and lifestyle advice. When indicated, the practitioner may recommend referral for laboratory tests or diagnostic imaging. 
    

3. Risks and Side Effects: Most treatments carry a low risk of harm. Possible side effects can include temporary soreness, light-headedness, fatigue, bruising or tenderness around the treatment area. Serious complications are extremely rare but may include nerve irritation, fractures or aggravation of underlying conditions. Dry needling and other modalities may involve their own risks, which will be explained prior to use. 
    

4. Benefits and Alternatives: Potential benefits include reduced pain, improved movement and function, and enhanced quality of life. Alternatives to the proposed treatment, including doing nothing, may be discussed. 
    

5. Authorisation to Refer: The parent/guardian authorises the practitioner to refer the child to another healthcare provider or for diagnostic tests if deemed necessary. The parent/guardian will be informed of any referrals. 

​

5. Privacy and Confidentiality 
 

1. Data Protection: All personal information will be collected, stored and processed in accordance with the Protection of Personal Information Act. Records will be kept securely for the period required by law. The practitioner respects the child’s privacy and will not disclose information without consent, except where required by law or ethical obligations. 
    

2. Research and Case Studies: Any publication or presentation of clinical cases will anonymise personal information. The practitioner will obtain specific consent before using a child’s case for teaching or research. 
    

6. Digital Communication and Recordings 
 

1. Telehealth: Telehealth consultations may be used when appropriate. The practitioner will ensure that privacy is maintained and that the child’s identity is verified. The parent/guardian may request an in-person consultation instead of telehealth. 
    

7. Duration of Consent and Withdrawal 
 

Consent remains in effect until the child’s condition resolves, or the parent/guardian or child (if capable) withdraws consent. Withdrawal of consent must be communicated to the practitioner. The parent/guardian remains responsible for any fees incurred up to the point of withdrawal. 
 

8. Mediation and Arbitration of Disputes 
 

Should a dispute arise in connection with this consent, a billing dispute or any treatment provided, the parties agree to first attempt to resolve the dispute by compulsory mediation, using a mutually agreed mediator in South Africa. If mediation fails to resolve the matter, the dispute will be referred to arbitration conducted in South Africa in accordance with the Arbitration Act 42 of 1965, using an arbitrator mutually agreed by the parties. This clause does not limit the right of either party to lodge a complaint with the Allied Health Professions Council of South Africa (AHPCSA) or any other competent authority but does limit the parties’ rights to litigate in a court of law on any aspect of this agreement not first mediated or arbitrated. 
 

Acknowledgement and Signatures 
 

I, the undersigned parent or legal guardian, confirm that I have read and understood this informed consent form, including the rights and responsibilities set out above. I have had the opportunity to ask questions and have received satisfactory answers. I understand that I may withdraw my consent at any time. By signing below, I acknowledge that I consent to the examination and treatment of the minor as described.