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Patient Consent Form - POPIA Act

About Dr Ackermann is an Orthopaedic Surgeon and specialist . He is the Best Hip and Knee Surgeon in Cape town, South Africa. He works from blaauwberg hospital in Cape town, Western Cape.


I, the undersigned:






Patient or parent/legal guardian of the Patient (as applicable) hereby give consent to Dr to Send or Retrieve my personal information (as defined in the Protection of Personal Information Act No 4 of 2013 (“POPIA”). This includes my personal details, medical information and medical history if needed to enable the Practice to provide the necessary health services.
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I understand that the aforementioned information is about me, or the Patient of whom I am the parent or legal guardian (of a child, incapacitated, or elderly person).
I understand that the Personal Information and Medical Information will be collected by the Practice in terms of the rules and regulations set out in POPIA.
I understand that my consent is voluntary, and that I can withdraw it at any time.

Thanks for submitting!