Make Your Booking

As a new patient, please fill out all blocks below with your information to streamline your first appointment with us.

Healthcare Professional

Informed Consent Form for Assessment and Treatment

I hereby give my voluntary consent to receive health or related services from:
Chiropractic Mobility Clinic- Dr.Tanita Seejarim

Clinical Examinations and Tests.

Therapy / Treatment / Procedure Benefits, Risks and Alternatives

Disclosure of Health Records

I understand that health records include among other things Personal (identifying) particulars of the patient, test results, imaging investigation results, audio visual records such as photographs, videos and tape-recordings; clinical research and other forms completed during the health interaction such as insurance forms, disability assessments and documentation of injury on duty.

I also understand that in order for the practitioner to claim from my medical aid scheme, certain information relating to my diagnosis will have to be shared with my medical scheme. If this information is not shared, then my medical scheme will not honour my claim.

I also understand that the practitioner may be under a duty to disclose some of my health records with other parties.

I consent to my health information/diagnosis being shared with:

Purpose: involved in management of my treatment
Purpose: as part of any legal issue between the patient and practitioner
Purpose: employment related matter
Purpose: Teaching/ training provided I remain anonymous in any journal or publication

Patient / Practitioner Confidentiality Towards Health Information and Records


Withdrawal of Consent

Disclaimer Notice / Indemnity

Person Responsible for the Account: