Name Surname Email Contact number ID / Passport number Date of Birth * State address Type of consultation Doctor call out Consultation Telemedicine virtual Consultation Pharmacy Telemedicine Consultation Message (Optional) Consent I/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. i / We hereby indemnify AGMS/CMS and hold AGMS/CMS 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. AGMS (Pty) Ltd may contact me by any one of the following communication methods/platforms/systems (“communications”); namely: phone, sms, email, social media platforms such as WhatsApp, Telegram, Signal or similar services or any future communications. I understand that these communications will be used for professional communication only. This will include (but not be limited to) diagnostic information, system updates, professional updates, prescriptions, and reports where necessary and indicated. I acknowledge that none of these communications are completely secure or encrypted communications, and you will not hold AGMS (Pty) Ltd responsible for any breach of confidentiality via these communications. Date * SUBMIT