Republic of the Philippines

Department of Health
PROVINCE OF ZAMBOANGA DEL NORTE
SIBUCO RURAL HEALTH UNIT
Sibuco Municipality, Zamboanga del Norte
Email: rhusibuco@gmail.com

CONSENT
I, __________________________________, parent/guardian/SO of ______________________________,
_____ years old and a resident of Purok____, Barangay_______________, Sibuco, Zamboanga del Norte,
hereby voluntarily allow my self/child/ward to:
1. Participate in/be given/be administered _______________________
activity/procedure/medication;
2. On this _______ day of _________________________, year 20______;
3. The activity/procedure/medication has been personally and fully explained to me and I have
understood the same to the best of my knowledge in the language known to me; and
1. Home Instruction/Health teaching on the aforesaid procedure/activity/medication which includes
but not limited to the benefits and outcome involved therein was clearly elaborated by the health
care provider

_____________________________________
Name and Signature of Patient/Parent/Ward
CONSENT
I, __________________________________, parent/guardian/SO of ______________________________,
_____ years old and a resident of Purok____, Barangay_______________, Sibuco, Zamboanga del Norte,
hereby voluntarily allow my self/child/ward to:
4. Participate in/be given/be administered _______________________
activity/procedure/medication;
5. On this _______ day of _________________________, year 20______;
6. The activity/procedure/medication has been personally and fully explained to me and I have
understood the same to the best of my knowledge in the language known to me; and
2. Home Instruction/Health teaching on the aforesaid procedure/activity/medication which includes
but not limited to the benefits and outcome involved therein was clearly elaborated by the health
care provider

_____________________________________
Name and Signature of Patient/Parent/Ward
CONSENT
I, __________________________________, parent/guardian/SO of ______________________________,
_____ years old and a resident of Purok____, Barangay_______________, Sibuco, Zamboanga del Norte,
hereby voluntarily allow my self/child/ward to:
7. Participate in/be given/be administered _______________________
activity/procedure/medication;
8. On this _______ day of _________________________, year 20______;
9. The activity/procedure/medication has been personally and fully explained to me and I have
understood the same to the best of my knowledge in the language known to me; and
p
3. Home Instruction/Health teaching on the aforesaid procedure/activity/medication which includes
but not limited to the benefits and outcome involved therein was clearly elaborated by the health
care provider

_____________________________________
Name and Signature of Patient/Parent/Ward