I hereby consent to my Executive Medical, which will consist of

- Completing a detailed medical history questionnaire
- Screening blood and stool tests
- A full general medical examination
- Resting and sub maximal exercise ECG test
- Lung function test
- Any other test deemed necessary by the conducting doctor, subject to discussion

In consideration of the above, and with intent to be legally bound, I hereby release the medical practitioners associated with this medical evaluation from any liability arising from or in any way associated with this evaluation or the data derived there from.

I understand that:
1. The data from these tests is to be considered preliminary only and does not necessarily constitute a diagnosis.
2. No test is 100% accurate and that each test has the potential to return false positive and false negative results
3. If any further tests or referrals arising out of this medical screening programme are necessary, these will be for my own account.
4. It is my responsibility to ensure that my blood tests are done 48-72 hours before my consultation.
5. The doctor will only discuss the results with me but the responsibility for initiating a follow-up examination to confirm the
results of this screening and obtaining further medical assistance is mine alone, and not that of the consulting doctor.
6. I will be required to perform an exercise test on a cycle ergometer or treadmill. This test is entirely voluntary. The test is associated with potential risks such as fainting, blood pressure changes, cardiac arrhythmias and in rare instances heart attack and stroke. Every effort is made to minimize these risks and should they arise, the necessary trained personnel and equipment are on hand to deal with the problem. You are responsible for fully disclosing any information that may place you at risk, and to report immediately any feelings of discomfort occurring during the test. Please feel free to ask any questions relating to the exercise test.
I consent to my medical data being used in research to improve the screening of risk factors within the company and South Africa. The data will not include any personal information. All disclosure regarding my results will only take place with my informed consent, which I hereby give voluntarily.