Waiver and Consent Form

Republic of the Philippines STA. BARBARA VILLAS 1 HOMEOWNERS ASSOIATION IN. SBV1HOA He!lth ente" Admin Bldg., Phase IV, Sta. Barbara Villas 1, Silangan, San Mateo, Rizal Tel No: 7!""#! WAIVER AND CONSENT FORM I, _________________________, ___ years of age, residing at Blk__, L__, Ph__, Sta. Barbara Villas 1, S Rizal am illing to !ndergone _________________ des"ite _________________________________________________. I a#knoledge that$ 1. %he attending "hysi#ian&n!rse ha'e e("lained my "hysi#al and medi#al #ondition, the "ro"osed a#tion "ro#ed!re and the risks it #o!ld take. ). I !nderstand the risk of the administration of the 'a##ine&s, in#l!ding the risks that are s"e#ifi# o!t#omes. *. I as able to ask +!estions +!estions and raise #on#erns ith the attending "hysi#ian&n!rse abo!t m the "ro#ed!re and its risks. My +!estions and #on#erns ha'e been dis#!ssed and ansered to my satis . I !nderstand that the attending "hysi#ian&n!rse and the SBV1- / -ealth 0enter free and harmless f #laims, demands or s!its for damages from in+!iry and #om"li#ations res!lting from the a#t, omissio the attending "hysi#ian&n!rse in the "erforman#e of his&her "rofessional d!ty "riorand d!ring the _________________. n the Basis of the abo'e statement$ I R 23 S% % -/V _____________________ % M B4 /%% 56I57 P-4SI0I/5&53RS . ____________________________________ Patient Signat!re o'er Printed 5ame&6ate

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Transcript of Waiver and Consent Form

Republic of the Philippines STA. BARBARA VILLAS 1 HOMEOWNERS ASSOIATION IN.
SBV1HOA He!lth ente" Admin Bldg., Phase IV, Sta. Barbara Villas 1, Silangan, San Mateo, Rizal
Tel No: 7!""#!
WAIVER AND CONSENT FORM
I, _________________________, ___ years of age, residing at Blk__, L__, Ph__, Sta. Barbara Villas 1, San Mateo, Rizal am illing to !ndergone _________________ des"ite _________________________________________________.
I a#knoledge that$
1. %he attending "hysi#ian&n!rse ha'e e("lained my "hysi#al and medi#al #ondition, the "ro"osed a#tion of the said
"ro#ed!re and the risks it #o!ld take. ). I !nderstand the risk of the administration of the 'a##ine&s, in#l!ding the risks that are s"e#ifi# to me and the likely
o!t#omes.
*. I as able to ask +!estions +!estions and raise #on#erns ith the attending "hysi#ian&n!rse abo!t my #ondition, the "ro#ed!re and its risks. My +!estions and #on#erns ha'e been dis#!ssed and ansered to my satisfa#tion.
. I !nderstand that the attending "hysi#ian&n!rse and the SBV1-/ -ealth 0enter free and harmless for any
_________________.
I R23S% % -/V _____________________ % M B4 /%%56I57 P-4SI0I/5&53RS.
____________________________________ Patient Signat!re o'er Printed 5ame&6ate