COVID-19 Case Form

I, the undersigned, do hereby acknowledge and agree that pursuant to the wellness monitoring program implemented and conducted by –

CSO CAPE TOWN NPC
(Registration Number 2012/068884/08)
(“CSO Cape Town”) (“the program”) for the benefit of patients that have tested positive for COVID-19 as well as patients that are displaying all the signs and symptoms for COVID-19 but are still either waiting to be tested or are waiting on their results, which program I have registered for, alternatively hereby register for,

I,

1) acknowledge and agree that it is a condition of my participation in the program, that neither CSO Cape Town nor its directors, members, employees or volunteers shall be responsible for any illness, injury or harm whether physical or otherwise to or death of any person, including me, nor for the loss or destruction of or damage to any property or any loss of money or loss of any other kind, including, but not excluding, loss of profits or other monetary loss and a claim for loss of financial support for anything happening as a result of my participation in the program, any advice or treatment given or omitted by CSO Cape Town or for the cost of any medical or other treatment, howsoever arising and whether anticipated [expected] or not. I accordingly indemnify (absolving from liability) CSO Cape Town and the abovementioned persons;

2) further agree to abide by [comply with] any reasonable advice, instruction or directive given to me by any CSO Cape Town member, whilst I am being monitored pursuant to the program;

3) understand that my participation in the program is of my own free will and volition and entirely at my own risk and is supplemental to obtaining advice and treatment from my own medical advisors and not a substitute therefor. I further acknowledge and agree that it is imperative that should there be a change in my condition, I must and shall immediately contact my local GP/physician, hospital or an Emergency Medical Service. This shall not be the responsibility of CSO Cape Town;

4) acknowledge and agree that CSO Cape Town may issue me with certain equipment, for use by me for such period as is determined by CSO Cape Town, in its sole discretion, which equipment may include an oxygen saturation device that will be able to monitor my oxygen levels and heart rate as well as a thermometer (should I not have one). As part of the program, CSO Cape Town may from time to time contact me (or a member of my family or household) and ask basic questions, such as:

• Do you/the patient have a cough?
• Does you/the patient have a sore throat?
• Are you/the patient feeling unwell?
• Are you/the patient experiencing shortness of breath?
• What is your/the patient’s respiration rate?
• What is your/the patient’s heart rate?
• What is your/the patient’s oxygen saturation?
• What is your/the patient’s temperature?

the answers to which may enable the CSO Cape Town COVID-19 wellness volunteer to determine a deterioration in my vital signs related to COVID-19 and advise me on the next steps, which may include:

• continued monitoring;
• contact GP/admission to hospital;

but on the strict understanding and agreement that CSO Cape Town shall in no way be responsible for any misdiagnosis, notwithstanding the answers to the above questions or otherwise and I hereby indemnify (to hold harmless/protect against/ absolve from liability) CSO Cape Town accordingly.

5) acknowledge that CSO Cape Town, at all times, retains the right to refuse me the right to participate in the program or to continue participating in the program at any time, at CSO Cape Town's sole discretion;

6) acknowledge and agree that any equipment issued by CSO Cape Town for my use shall remain the sole property of CSO Cape Town and I agree that I shall look after and safeguard the equipment and return same to CSO Cape Town in good order and condition, upon request.