Republic of the Philippines Province of Surigao del Sur MARIHATAG DISTRICT HOSPITAL Marihatag, Surigao del Sur PATIENT

CONSENT FORM

Case No: _________________________________ Date: ____________________________________ Patients Name:

CONSENT FOR HOSPITAL CARE

Permission is hereby given to the medical, nursing, laboratory and radiology staff of Marihatag District Hospital to perform such diagnostic procedures and administer such medications and treatments as may be deemed necessary or prescribed by my attending physician(s), whom I have voluntarily chosen/ accepted to treat me/ the patient _____________________________ during this confinement. It is understood that such procedures may include blood transfusion, intravenous or other injections and other diagnostic tests and procedures. I hereby acknowledge that such procedures may result in complications which either cannot be foreseen or avoided. Accordingly, I agree to relieve Marihatag District Hospital, its officers, employees and members of its medical staff from liability or responsibility for any complications that may arise in connection with any procedure or treatment done on me/ above- named patient during this confinement, for as long as there is no negligence on the part of the attending physician(s) and/ or hospital personnel.

______________________________ Patients Signature over Printed Name

Party responsible for patient in case patient is a minor or unable to sign. __________________________________ Signature over Printed Name Relation to Patient: __________________ Date: ________________________

Witness: _____________________