Patient Form

Gustaf Pretorius
Clinical Psychology Practice
621 Olivia Street · Garsfontein · Pretoria · 0042 · Cell: 082-320-2726
Information Officer: Gustaf Pretorius
Certificate 2025-006159 · https://www.psydev.co.za/privacy

Purpose of Engagement

Check the box that best describes your reason for the appointment.

SA ID / Passport Number*

Treating psychiatrist/psychologist

If applicable

Medical aid Scheme Number

Emergency Contact Name

Emercency Contact Number

What data will be processed and why.

Purpose	Categories of personal information	Legal basis
Diagnosis, treatment & continuity of care	Clinical notes, psychometrics, medication, risk assessments	POPIA § 11(1)(c) – performance of obligations in the patient’s interest; § 34(1)(b) competent-person consent
Medical-aid reimbursement & debt recovery	ID, membership number, ICD-10 codes, invoices	POPIA § 11(1)(c); Medical Schemes Act
Secure back-ups (SA + EU/US/CH)	Encrypted replicas of entire record	POPIA § 57 + Standard Contractual Clauses
Teaching / research (de-identified)	Redacted case material	POPIA § 27(1)(d) – opt-in only

Parent / Guardian / Competent Person Information

Full Names (Parent / Guardian 1)

By typing my full name above I confirm that the above information is correct and that I have read and understood the consent statements.

Full Names (Parent / Guardian 2)

By typing my full name above I confirm that the above information is correct and that I have read and understood the consent statements.

Purpose of Engagement

Patient

Medical Aid

Emergency Contact

Consent

Data Processing

Parent / Guardian / Competent Person Information