Patient information & Consent

Please complete this form only after your appointment has been confirmed by Wound Well.
This form collects information required for your appointment and records your consent to an initial wound assessment.
Completion of this form does not constitute consent to every possible treatment or procedure.
Following the assessment, any recommended treatment will be discussed with you. This will include its purpose, expected benefits, material risks, alternatives and likely costs. Additional consent will be obtained where required.
Completing this form does not replace an in-person assessment and does not create an emergency-care service.

Patient Details

First name

Last name

Phone

ID/Passport number

Birthday

Year

Month

Day

Multi-line address

Country/Region

Address

City

Zip / Postal code

Next of Kin/Emergency contact Name & Surname

Contact Number

Relationship to patient

Medical Aid Details

Private Patient

Main Member Name

Main Member ID

Medical Aid Name

Plan

Number

Patient Dependent code

Medical information

Are you allergic to any food or medication?

Yes

If yes, please specify

Date Wound started

Do you smoke or make use of tobacco products?

Yes

List ALL medications you take including supplements & over the counter. Include Dosages.

Location of wound & Cause

IMPORTANT

Submitting this form does not provide emergency assessment or guarantee an immediate response.

For severe bleeding, rapidly spreading redness or swelling, sudden black or purple discolouration, fever with worsening symptoms, confusion, breathing difficulty or another medical emergency, attend the nearest emergency department or contact emergency services.

Name of GP/ Specialist

PHOT OF WOUND: You may upload a wound photograph to assist with preparation for your appointment. A photograph cannot replace an in-person assessment or be used on its own to diagnose the wound.

Upload a copy of your ID

Consent to initial assessment

I consent to wound I consent to an initial wound assessment .

I consent to routine wound cleansing and application of a suitable dressing where clinically appropriate and after the proposed care has been explained to me.

I understand that the assessment may identify the need for additional treatment, investigations or referral to another healthcare practitioner.

I understand the purpose, risks, benefits, and possible complications of my treatment and that my treatment plan may change based on my wound's progress.I acknowledge that no healing outcomes can be guaranteed

I understand I may be referred to other specialists if clinically indicated

TERMS & CONDITIONS- CLINIC ATTENDANCE

I understand that regular prescribed appointments are necessary to manage my wound & I agree to attending these as recommended.

I understand that wound care is an ongoing process for most patients, requiring continuous clinic visits and active management, rather than a one-time intervention.

I Understand that Wound Well is not a 24 hour facility, should I need urgent care I agree to attending my nearest emergency center/hospital.

TERMS & CONDITIONS- PAYMENTS

I understand consumables (dressings, ointments, etc.) are charged per item. I understand extra procedures, like debridement, will incur additional charges

Payment methods accepted: Card, Eft, or 3 month payment arrangements on request.

FEES

Private patient fees:

First consult Extensive Wound R750: EXCLUDES dressings & consumables

First Post Op R600- Includes basic dressing (If you require advanced dressings this will be discussed in your appointment)

Follow up Extensive Wounds R550 : Consumables EXCLUDED

Post Op Follow up R480: INCLUDES basic dressing

Home visits R150: Additional to above rates, for home visits in designated areas.

Dressings & Materials: All materials used are charged seperately & additionally to consult & follow up fees.

These fees are ONLY an estimate & any additional serivces/materials will be charged

Medical Aid patient fees:

This practice charges above medical aid rates

Co-payments are due on the day of your appointment, any short falls occurred after your appointment remains the patients responsibility for payment.

Initial wound assessment: R600 payable on the day- This will be refunded once payment is received by medical aid

Authorisation is required by your medical aid to be covered from risk benefit otherwise claims are deducted from medical savings.

Authorisation can only be applied for after your first consult which requires full payment.

In Hospital patients- Consult fees must be paid privately as medical aids do not cover in hospital wound management unless VAC therapy is being done.

TERMS & CONDITIONS- POPI ACT

I understand that: My personal information will be used solely for healthcare services, medical records, invoicing, and related administrative purposes. Wound Well will take reasonable steps to protect my data against loss, unauthorised access, or misuse. I understand my treatment plan may be discussed with other health practitioners to ensure a holistic multidisciplinary treatment approach.

I consent to photographing & videoing of my wound/s for the purpose of record keeping. I understand these images/videos may be shared with other relevant healthcare professional & may be used for educational purposes.

By signing I agree to and understand the above terms & Conditions & have noted the full T&C's available on our website

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