MARIANO MARCOS MEMORIAL HOSPITAL AND MEDICAL CENTER

City of Batac, Ilocos Norte

TO WHOM IT MAY CONCERN

I, ____________________________________________ , years old, married/single/widowed hereby

consent to the performance upon __________________________________.
Myself

Who is my __________________ the procedure/operation/anesthesia hereunto stated after these have

Relation

been fully explained to me by the doctors and concerned including the risk involved and their alternative
procedure.

Explained by
Procedure/Operation/Anesthesia (Signature over printed Name
Of the Attending Physician)

I also consent for the proper disposal by the authorization of the _________________________
Patient
Or whatever tissue maybe removed form myself/t/

I also consent to the taking of photographs in the course of this treatment of operation for the
purposes of advancing technical knowledge.

IN WITNESS WHEREOF, i hereunto set my hands this _______________________________ __________

of ____________ 20____________ at_______________________________________________.

_______________________________________
Patient’s signature or thumb mark
of the person giving free consent

IN THE PRESENCE OF

________________________ _______________________________
Witness Address

________________________ _______________________________
Interpreter Address