1Tick.co.za Digital forms Consent for medical and surgical procedures example It looks like your internet is very good, do you want to synchronize the data? Total Signed: Total Returning: Sync data Thank you for completing our waiver form. Your submission for Consent for medical and surgical procedures example event was processed successfully. Hi - welcome! Please let us know if you are a new customer, or a returning customer.... Make a selection New customer Returning customer (please use same email address). Name * Surname * email * Are you a new customer? I'm a new customer Are you completing this on behalf of a minor? Make a selection No Yes For legal Guardian (All fields compulsory) Guardian Full Name and Surname * Relationship to minor * Guardians valid Email Address * Guardians contact number (also for emergencies) * Minor 1 Remove Minor's name * Minor's Surname * Minor's date of birth * Day1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MonthJanuary February March April May June July August September October November December Year2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Minor's gender * Make a selection Male Female Minor's age * Make a selection 123456789101112131415161718 Any medical conditions * Make a selection Yes No INSERT DETAILS HERE Add another minor First name First name * Last name Last name * Email Email * Contact Number Contact Number * Medical practice name Medical practice name * Any medical conditions we need to be aware of? Any medical conditions we need to be aware of? * Make a selection Yes No Emergency contact person Emergency contact person * Emergency contact number Emergency contact number * Age Age * Make a selection 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 32 33 34 35 36 37 38 39 40 41 42 43 44 45 46 47 48 49 50 51 52 53 54 55 56 57 58 59 60 61 62 63 64 65 66 67 68 69 70 71 72 73 74 75 76 77 78 79 80 81 82 83 84 85 86 87 88 89 90 91 92 93 94 95 96 97 98 99 100+ Full Physical Address Full Physical Address * Medical Aid Medical Aid * Medical Aid Number Medical Aid Number * Procedure Date Procedure Date Day1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 MonthJanuary February March April May June July August September October November December Year2027 2026 2025 2024 2023 2022 2021 2020 2019 2018 2017 2016 2015 2014 2013 2012 2011 2010 2009 2008 2007 2006 2005 2004 2003 2002 2001 2000 1999 1998 1997 1996 1995 1994 1993 1992 1991 1990 1989 1988 1987 1986 1985 1984 1983 1982 1981 1980 1979 1978 1977 1976 1975 1974 1973 1972 1971 1970 1969 1968 1967 1966 1965 1964 1963 1962 1961 1960 1959 1958 1957 1956 1955 1954 1953 1952 1951 1950 1949 1948 1947 1946 1945 1944 1943 1942 1941 1940 1939 1938 1937 1936 1935 1934 1933 1932 1931 1930 1929 1928 1927 1926 1925 1924 1923 1922 1921 1920 Procedure description Procedure description Have you been made aware of the risks? Have you been made aware of the risks? Make a selection YES NO Language Language * Make a selection English Afrikaans Albanian Arabic Armenian Basque Bengali Bulgarian Catalan Cambodian Chinese Croatian Czech Danish Dutch Estonian Fiji Finnish French Georgian German Greek Gujarati Hebrew Hindi Hungarian Icelandic Indonesian Irish Italian Japanese Javanese Korean Latin Latvian Lithuanian Macedonian Malay Malayalam Maltese Maori Marathi Mongolian Nepali Norwegian Persian Polish Portuguese Punjabi Quechua Romanian Russian Samoan Serbian Slovak Slovenian Spanish Swahili Swedish Tamil Tatar Telugu Thai Tibetan Tonga Turkish Ukrainian Urdu Uzbek Vietnamese Welsh Xhosa Capture Photo By completing and submitting this form you are agreeing to the following: Stuck with paper forms, or unwanted PDF’ Word documents or outdated books? I’ll walk you through how our 1Tick digital forms can make your life a breeze when it comes to getting those indemnities/waivers/CONSENT/T&C’s signed electronically. Why should you make the switch? Well, with digital forms, you get: A Physical signature or Tick box signature A Date, time, and IP address stamp. Clear and readable data (no more deciphering messy handwriting!) Secure online storage at no extra cost Automation to save you valuable time Custom branding to add your personal touch Integrations for smooth operations to MEWS pms, Floodin.com No more dealing with printing or scanning, dogs ear paper on old clipboards Automatic emails to clients with signed forms in PDF. Back-office access from your favorite comfy spot on any device Unlimited questions to cover all your bases, drag and drop, EDIT and sort Professional and super easy for your clients, share your unique link through WhatsApp, email, text message, or even on-site with a QR code. Dashboard to see all your demographics in one view. Let your clients scan a QR. Instant Export data to Excel or CSV file for marketing and review purposes It’s a game-changer that saves you money, time, and admin hassle. Ready to give it a shot? Just hit up our sign up page for PRICING. No strings attached – you can bail anytime if it’s not your vibe. Questions or just want to chat? I’m all ears! Cheers, 1Tick Team www.1tick.co.za Whats App Business – +44 7922460249 1Tick Team info@1tick.co.za Thanks for checking out our demo. Signature *
