MEDICAL COLLEGES OF NOTRHERN PHILLIPINES

Alimannao Hills, Penablanca Cagayan

COLLEGES OF RADIOLOGIC TECHNOLOGY

February 18, 2018

Dear Sir/Madam:
Warmest Greetings!
We the undersigned students of Medical Colleges of Northern Philippines are currently taking our
Affiliation of Radiologic Technology Internship here in Baguio General Hospital and Medical Center
would like to ask your permission to allow us to conduct a survey questionnaires regarding the patient
information of __________________________________. This is in view of our case study, entitled,“
Abdominal Plain and Contrast CT Scan: A Study of Bilateral Renal Cortical Cysts”.
Attached herewith is the survey questionnaire for this study. The survey would last only about 10-
15 minutes and would be arranged at a time convenient to the patients’ schedule. Participation in the
survey is entirely voluntary and there are no known or anticipated risks to participation in this study. All
information provided will be kept in utmost confidentiality and would be used only for academic
purposes. The name of the patient will not appear in any case or publications resulting from this study
unless agreed to. If you agree, kindly sign below acknowledging your consent and permission for us to
conduct this study. Your approval to conduct this study will be greatly appreciated. Thank you in advance
for your interest and assistance with this case study.

Sincerely,

Cunal, Diana Rose S.

Davis, Brenda May G.

Guiyab, Arvin B.

Notarte, Froilan M.

Solmayor, Joan C.