PATIENT CONSENT FORM FOR CONSULTATION

PATIENT NAME: Princess Cassidie Veera Jurado

HOME ADDRESS: 24 essen st. Bf homes Paranaque city
CELLPHONE NUMBER: 0919 998 7319
DATE OF CONSENT Nov 16 2020
SIGNED:
To comply with RA 11332, you are obliged to give truthful answers to the following questions about
your health condition and possible exposure.

This questionnaire is to protect both the patient and the staff during and after the consultation and
procedures in our clinic. Please help us make this possible by answering the following:

Yes No
Does anyone in the household have fever? 
Does anyone in the household have sore throat? 
Does anyone in the household experience cough and colds? 
Does anyone in the household have shortness of breath/difficulty in breathing? 
Does anyone in the household have muscle pains? 
Does anyone in the household have diarrhea? 
Has anyone in the household consulted with a doctor about the above symptoms? 
Does anyone in the household have history in the past 2 months? 
Where:
When:
Has anyone in the household been in contact with a person with history of travel? 
Has anyone in the household been exposed to people with the symptoms above? 
Has anyone in the household been tested for COVID? 
Does the patient have any allergies? 
What:

I hereby certify that the information I have provided are true, correct and complete. I understand that
I will be held criminally liable for failure to give right of information or intentionally providing
misinformation.

I hereby authorize Ma. Concepcion Tan-Paulino, MD/ Rey Magno T. Paulino, MD/ Jose Antonio T.
Paulino, MD to do the consultation/immunization/procedures that I have inquired for.
Signature of Patient/
Person authorized to sign for patient: Marie Joy G. Jurado Date: Nov 16 2020

If authorized person,
Relationship to patient: Marie Joy G. Jurado (Grandmother)

Witness: _____________________________________ Date: Nov 16 2020