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By clicking SUBMIT above, (“I / we / the Company”) hereby confirm that we have been authorized by the above named person to receive and process any personal information pertaining to you or your clients and / or third parties for the purpose of rendering the following services of AGMS / CMS. We agree that in processing any personal information provided by you to us, we do so strictly in accordance with the requirements of the Protection of Personal Information Act 4 of 2013, including the information security requirements set out in Sections 19 to 22 thereof. We and you agree that we will notify you immediately on our becoming aware of any security compromise in respect of personal information provided to you by us and to comply with any lawful instruction by you, or of the person to whom personal information held by us relates, or by any competent authority. We hereby indemnify you and hold you harmless against any claim of any nature by any person arising out of any breach by us of POPI, relating to the personal information that you have provided to us, including any administrative fines or penalties, damages of any type and any legal expenses incurred. By providing Patient’s e-mail address to AGMS, I authorizes AGMS to communicate with Patient by e-mail regarding Patient’s "protected health information" ("PHI") and Patient understands and agrees to the following: E-mail is not necessarily a secure medium for sending or receiving PHI and, accordingly, any third party may gain access to such PHI; Although AGMS and its Doctors will make all reasonable efforts to keep e-mail communications confidential and secure, neither AGMS nor its Doctors can assure or guarantee the absolute confidentiality of such e-mail communications.