Online Patient Consultation Information Form

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Cancer? YesNo

Primary ovarian failure (<40)? YesNo

Active thrombophlebitis or thromboembolic event? YesNo

Pituitary tumours? YesNo

Hyperprolactinaemia? YesNo

Pregnancy and breastfeeding? YesNo

Bipolar? YesNo

Crohns disease or Ulcerative colitis or severe IBS? YesNo

Remission renal failure? YesNo

Breastfeeding? YesNo

Gastric bypass? YesNo

Type 1 Diabetes? YesNo

Are you allergic to Warfarin? YesNo

Are you allergic to Iodine? YesNo

Are you allergic to Mushrooms? YesNo

Do you suffer from Pheochromocytoma? YesNo

Any SSRI's? YesNo

Plasmaquine in SLE? YesNo

Do you suffer from Pheochromocytoma? YesNo

Are you allergic to fish? YesNo

By clicking here, I confirm that: [the undersigned, hereby unconditionally accepts the treatment of Dr A Kok at Supreme Aesthetics (“The Practitioner”) for the Slender Wonder Weight Loss Programme (“SWWLP”), and 1. confirm that: 1.1 I am fully aware of The Practitioner’s tariffs and accept them unconditionally. 1.2 If you miss an appointment without timeous cancellation, you are liable for the consultation fee, since we have to accommodate other patients. 1.3 The SWWLP may be repeated with my express written consent. 1.4 I am aware of the fact that my medical scheme does NOT pay for the SWWLP because they deem it to be cosmetic treatment, and I accept responsibility for payment of the amount due for professional services rendered and medicine dispensed and supplied and products purchased, and supplied. 1.5 No action will be taken against The Practitioner on the grounds of misrepresentation, or the absence of informed consent by me, during the SWWLP. 2. request and authorize The Practitioner to prescribe and order all medicines required by me for purpose of the SWWLP from Scriptchem Compounding Services, the Slender Wonder Pharmacy, and for the pharmacy to compound and deliver the prescribed medicine to the physical address of The Practitioner on my behalf, for which purpose this request and authority shall constitute my express written consent and authority for The Practitioner to contract with the pharmacy on my behalf. 3. confirm that this contract, read with my patient details, and SWWLP documentation, the medicines prescribed, admixed, compounded and supplied, and the products ordered by me from time to time, contains all the agreed terms between The Practitioner and me as patient, and no other agreement or promise, oral or written, will be valid, unless reduced to writing and signed by both The Practitioner and I.] [/acceptance]

By clicking here, I do herewith understand and accept that: [I hereby consent to the personal information provided by me to be used for delivery of services offered by Slender Wonder. It is my legal obligation to provide correct information in the contracting with Slender Wonder and where such information has been changed, I am obliged to inform Slender Wonder accordingly. I am aware that I can unsubscribe to any newsletters, campaigns, communications from Slender Wonder by notifying them accordingly. It is my right to request Slender Wonder to delete and cease to use any of my personal information subject to any legal obligation on Slender Wonder’s side to keep same. There is a legal obligation for Slender Wonder to retain your information for 5-years from date of contracting, whereafter it will be destroyed in a POPIA compliant manner. Should I believe that there has been a misuse of my personal information, I am aware that I can lodge a complaint with Slender Wonder and / or the Information Regulator at inforeg@justice.gov.za] [/acceptance]

I certify that my answers are true and complete to the best of my knowledge.

I hereby acknowledge that I understand and agree to the above mentioned statements.