"There are different reasons a person consults with a Urologist. Sometimes you are referred by your GP for something which concerns him or her — which we will definitely give attention to — but if there is one thing you personally would hope to find a solution to today, what would that be?"

If you do not have a medical aid and intend to pay privately for our services, please read the following section carefully before signing.

Important Information for Self-Pay / Private Paying Patients

Our Commitment to You
At our practice, we are committed to providing safe, ethical, and high-quality medical care. All treatment decisions are based on international medical guidelines and sound clinical judgement. Your care is never influenced by whether you have medical aid or are paying privately.

1. Initial Consultation includes:

• Medical consultation and examination
• Uroflow test (if required)
• Ultrasound examination of the urinary tract or genitalia (if indicated)

Not included: pathology, radiology, medication prescriptions, additional consumables.

2. Procedures Performed in the Rooms

You will receive a quotation beforehand covering the procedure and consumables used. Not included: medication after the procedure, pathology or radiology tests, costs related to other healthcare providers.

Please note: All procedures carry a risk of complications. If complications occur, the treatment and costs related to managing them are not included in the original quotation.

3. Procedures Performed in Hospital

You will receive separate quotations for hospital costs, anaesthetist fees, and surgeon's fees. Surgeon's fees are based on rates similar to those paid by medical schemes on the Discovery Classic Plan.

Additional costs not included: pathology tests, radiology tests, allied services.

Payment Policy

All accounts must be paid in full before or during hospital admission.

Follow-Up After Surgery

• One follow-up visit after surgery is included in the surgical fee.
• Additional follow-up visits will be billed separately.
• If the initial procedure was diagnostic only, a new quotation will be provided for further treatment.

If you have any questions about your treatment or costs, please feel free to discuss them with us.

✅ By tapping Next, you confirm that you have read and understood the above information for private paying patients.

CONDITION OF SERVICE / DIENSVOORWAARDES

I, the undersigned/patient/legal guardian/guarantor of the patient, hereby acknowledge:

• The Practice's bill is issued separately from the hospital's bill.
• Your medical aid scheme will pay based on the specific plan and option you have chosen, along with the scheme's guidelines. If the Practice's fees are higher than what your medical aid covers, you will need to pay the remaining balance.
• I agree to be responsible, either on my own or together with the patient, for paying any amount owed to the Practice for medication, medical supplies, and/or services provided or to be provided to the patient.
• I agree that if an account remains unpaid for any reason and is sent to an attorney for collection, I will be responsible, along with others if applicable, for all legal costs on an attorney-and-client basis.
• If applicable, I confirm that: I am a genuine member of the mentioned medical aid scheme; the patient is a genuine member or dependant; there are sufficient funds available for the patient; I have not been declared bankrupt and do not have any legal or contractual restrictions.
• Authorisation for the procedure or consultation does not guarantee payment. Payment will depend on your medical aid membership being active and having enough benefits on the treatment date.
• I give permission for the Practice or its agent to submit any bill owed to the Practice to my medical aid scheme for payment.
• I give permission for the Practice and its agent to collect and store all personal information related to health records for me and my medical aid dependants, along with information about treatments, medications, appointments, procedures, and medical aid claims.
• WhatsApp Communication Consent: I consent to the practice contacting me via WhatsApp (using the official practice number) for communication purposes, which may include appointment reminders, administrative matters, and sharing of medical information such as investigation results. I understand that while WhatsApp uses end-to-end encryption, it is not a secure medical records system and carries potential risks of unintended access. I accept these risks and indemnify the practice accordingly. I understand that I may withdraw this consent at any time in writing.
• To support accurate clinical record-keeping, the practice may use secure ambient technology during consultations; no audio recordings are retained, data is processed in accordance with POPIA, and patients may opt out at any time.
• Patients making use of medical insurance policies (and not medical aid schemes) will be treated as private-paying patients and are responsible for submitting their own claims to their insurer.

Please contact the practice account department if you require assistance regarding your account at: caro@knightprac.co.za or call 010 020 3928 / WhatsApp 084 099 3691.

📜 By proceeding to the signature page, you confirm that you have read and understood the above Conditions of Service and POPI consent.

I declare that all the information provided in this form — including my registration details, demographic details, medical history, allergies, lifestyle, and any scoring questionnaires — is accurate and complete to the best of my knowledge. I understand that this signature confirms my responsibility for everything submitted today.