I hereby give permission to Dr H Niemöller /associated colleagues and assistants in his employ, to treat the condition diagnosed, with regards to my hospitalization. I give permission for them to perform surgery and or diagnostic procedure which is known to me as below.


The operation and or diagnostic procedures has been explained to me in general, understandable terms by Dr H Niemöller, and I understand what I have been told. Dr H Niemöller has explained the benefits of this operation and or diagnostic procedure to me. I understand the risks, dangers, complications and consequences associated with my surgery, anaesthesia and further procedures. I have also been informed of alternative methods of treating the condition


It has been explained to me that there might be unforeseen complications or circumstances during surgery. This may lead to improvisation and/or change regarding the procedure detailed above. I hereby give permission to Dr H Niemoller and his colleagues and assistant to improvise during surgery, to the best of their academic knowledge, in order to provide the best possible outcome for the surgery.

Consent in this paragraph includes all treatment of conditions that were not known to Dr H Niemöller at the start of the surgery.

I hereby grant consent to any hospital and other health care services that are medically indicated or that the doctor may prescribe or require including any surgery, radiology or diagnostic examination, aesthetic, blood or blood product infusion, or laboratory tests (including an HIV test in the event of a needle-stick injury to one of the healthcare team) for me/the patient.


The doctor explained to me that other physicians and health care providers will participate in my/the patient’s care. I therefore extend this authorization to these physicians and health care providers. I understand that I am/the patient is responsible for the fees as explained to me by the doctor. or, if not specifically explained, for the customary fees for any services. I understand that I/the patient may be responsible for co-payments for any orthopaedic prosthesis/implants, bone graft/substitutes required, hospital co-payments or any other expenses that are not covered by my Medical Aid.


I give consent for the administration of blood products, either during or after surgery, if the need arises. I understand that the administration of blood products (blood transfusion) has associated risks which have been explained to me by Dr H Niemöller. These include but are not limited to fever, rash and allergic reactions. HIV and viral hepatitis are possible diseases which can be transmitted via blood transfusions and I am aware of this. I am also aware that I may donate my own blood or I may ask for a specific blood donor to provide blood for me, if time allows for this.


I have also been informed of the risks of complications such as excessive blood loss, infection and heart attack that can associate any surgical procedure performed. I am also aware that medical science and surgery is not an exact science. I am aware that there is no absolute guarantee regarding the results of the above-mentioned surgery, procedures and diagnostic tests


I give further consent for the destruction or re-use of any human tissue/ part during the duration of the surgery. This is strictly done according to the law.


I also give consent that medical representatives from the company supplying the material necessary to perform the surgery are allowed in theater.


I also give consent that photographic and or videographic material may be taken during the surgery, for educational purposes. I am aware that my identity will never be made known either in photographic, videographic or in written material. 


I acknowledge that the following conditions specific to the COVID-19 pandemic have been explained to me and I understand that:

  • There are general risks attached to COVID-19 infection and that viral shedding during the prodrome period and that a significant proportion of patients in SA appear to be COVID-19 positive with no symptoms at all.

  • There is no current treatment for COVID-19 and that vaccines are unlikely to be available for at least 6-12 months.

  • COVID-19 infection carries a risk of death and this is increased with age, the presence of comorbidities and the duration of the surgical procedure.

  • Despite feeling completely well I/we may still be or become infected with the COVID-19 virus and there is a significant risk of serious illness or dying after any surgical procedure as a result of this infection.


I take note that Dr H Niemöller is practicing in his own capacity ant that he is not affiliated with any hospital group. He can also not be held liable for the actions of any hospital personnel or therapists


Please note that it is your own responsibility to obtain your prosthetic limit from your medical aid and to inform Dr H Niemöller in order to make sure that the implants used will not result in extra costs for your account


After discussing the above, the Dr H Niemöller gave me an opportunity to ask questions and seek further information. I do not require further information and I am prepared to consent to him/her proceeding with the recommended operation. I believe that the doctor has honoured my right to make my own informed health care decision. I give my consent voluntarily and freely and certify that I can give valid consent. I understand that I can revoke my consent to the operation at any time up until the time the operation process has started. I also consent to my/the patient’s personal information including information relating to my/the patient’s health and treatment being processed or given to any person necessary in relation to the operation and related treatment and payments due. In the event of allegations of negligence, I agree to embark on mediation prior to embarking on litigation.

Procedure(s) being performed that I give consent to is / are:

Thank you for submitting your consent.

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