Dr Nicky Cockburn: Patient Information and POPI Form

Patient Information

Medical Aid Information

Next of Kin:

Patient Consent to process personal information.

I, , hereby consent to the processing of my personal information contemplated in the Protection of Personal Information Act No 4 of 2013, by Dr Cockburn, the practice staff and third parties with whom Dr Cockburn has a contractual relationship for the following purposes.

Treating and managing me in terms of doctor-and-patient relationship;
The administration of the contractual relationship between myself and Dr Cockburn;
Communicating with third parties who have undertaken to indemnify me for the costs of my treatment and management or part thereof including medical schemes and their administrators where relevant;
Collecting monies outstanding from me.

Signature:

Clear