Patient consent form.

Version 1.0 · Effective date: [TO BE CONFIRMED] · Issued by HorizonCare Pty (Ltd)

This form is intended for patients using HorizonCare’s remote healthcare services. It supplements, and does not replace, information given during a clinical consultation. Please read it before consenting.

1. Provider details

Service organisation: HorizonCare Pty (Ltd) · Registration number: 2025/228903/07
Contact: +2768 6054159 | info@horizoncare.co.za

2. Nature and scope of telehealth

HorizonCare may provide consultations by telephone, video, secure messaging or another agreed digital channel. Services may include history-taking, clinical advice, prescribing when clinically appropriate, requests for investigations, referrals and follow-up. The treating clinician will determine whether remote care is suitable for the presenting problem. No diagnosis, prescription, medical certificate or specific clinical outcome is guaranteed.

3. Limitations and risks

Remote assessment may not permit a full physical examination or immediate testing. Audio/video quality, network interruptions, inaccurate or incomplete information and technology failures can affect assessment. The clinician may require an in-person consultation, emergency care or referral before providing further advice or treatment. The patient may decline or stop a telehealth consultation, subject to applicable fees and clinical safety considerations.

4. Emergencies and escalation

HorizonCare telehealth is not a substitute for emergency medical services. If symptoms suggest an emergency—including severe breathing difficulty, chest pain, stroke symptoms, major bleeding, altered consciousness or immediate danger—the patient must contact local emergency services or attend the nearest emergency department without waiting for a telehealth response. In South Africa, 112 can be dialled from a mobile phone. The clinician may recommend urgent face-to-face assessment and document that recommendation.

5. Patient responsibilities

I agree to provide complete and accurate information about symptoms, medical history, allergies, medications and relevant prior care; to disclose my current location and a reliable callback number when needed for safety; to participate from a reasonably private setting where possible; to follow agreed safety-netting and referral instructions; and to seek further care if symptoms persist or worsen. I understand that withholding material information may affect clinical decisions.

6. Privacy, records and POPIA

HorizonCare and the treating healthcare professionals will process personal and special personal information, including health information, to provide care, manage clinical records, communicate about treatment, administer services and meet legal/professional obligations. Access will be restricted on a need-to-know basis and reasonable safeguards applied. Information may be shared with laboratories, pharmacies, referral providers, medical schemes, technology processors or emergency services when justified and lawful. Information may also be disclosed when required by law. I may request access to or correction of records subject to applicable law. Retention periods will follow applicable legal and professional requirements. HorizonCare’s full Privacy Notice must be made available to patients separately before consent is obtained. For privacy enquiries or to request the notice, contact info@horizoncare.co.za.

7. Communication and technology

I consent to being contacted through the channels I provide for appointment, clinical follow-up and service-related communication. I understand that ordinary email, SMS or messaging may carry privacy risks and that urgent symptoms should not be reported through unattended channels. Consultations will not be audio/video recorded without a separate appropriate basis and notice or consent. Any third-party platform will be governed by the applicable privacy arrangements.

8. Fees and payment

The applicable consultation fee, payment arrangements, medical scheme terms (if any), cancellation terms and any additional charges for investigations, medication or external providers will be communicated to me before I incur those charges. I may request a written explanation of fees and payment terms from HorizonCare. Clinical care and patient rights are not waived because of a payment dispute.

9. Acknowledgement of risk and lawful limitation of liability

I understand the inherent limitations and reasonably foreseeable risks of telehealth explained above and voluntarily agree to receive remote care where clinically appropriate. I acknowledge that outcomes cannot be guaranteed. Nothing in this form excludes or limits liability that cannot lawfully be excluded, including liability for negligent care where such exclusion is prohibited, nor does it waive my statutory rights or my right to lodge a complaint with an appropriate regulator or professional body. This form is not an agreement to indemnify HorizonCare or a clinician against their own negligence.

End of form. Continue to give your consent.