PHILHEALTH ACCREDITED

Hospital Case No.:___________

CONSENT FOR CONFINEMENT AND PHYSICIAN SERVICE

I, the undersigned, of legal age, married/single, and Filipino, do hereby voluntarily consent to
have me and/or my patient: ____________________________________ be confined at Metro Pagadian
Specialist Hospital Incorporated (MPSHI);

I, the undersigned do hereby voluntarily consent to have me and/or my patient undergo

diagnosis and/or medical/surgical treatment with no hesitation to be under the service of my preferred
physician namely ___________________________________ specializing in ____________________with
the knowledge that he/she has the capabilities to perform medical and ethical judgment/s without
outside interference or influence in dealing me or my patient’s medical/surgical condition;

I, the undersigned voluntarily consent on the possibilities of being subjected for co-
managements to other physician/s or specialist/s as demanded necessary by my present
medical/surgical condition;

That in the case of emergency, when my attending physician is not, for the meantime available, I
am expressly consenting that any medical and/or nursing staff of the hospital may do and institute that
whatever is necessary for my condition at that particular time of emergency;

That, in the event of emergency and in the absence or unavailability of one to give consent in
my behalf or for my patient for a certain procedure, I, explicitly consent to hereby authorize any staff of
the hospital to do and institute whatever is necessary for emergency affecting me and/or my patient for
the meantime that me and/or my patient’s attending physician/s is not around;

That I was expressly informed and fully understood that my attending physician shall employ the
standard of care required for me and/or my patient’s medical/surgical condition even if the attending
physician/s is/are not an employee/s but is/are an independent contractor/s of the hospital and I
understood that the hospital has no control or supervision over the medical/surgical management of me
and/or my patient’s condition. Further, it is my understanding that the staff nurses are fully licensed to
practice their profession and that they were appointed according to the credentials they have presented
to the hospital so that their respective duties in the exercise of their profession as licensed nurses are
their sole responsibility and not of the hospital;

I, expressly acknowledge that my rights and responsibilities were explained to me and/or to my

lawful representatives in a language and/or dialect spoken and understood by me and/or my lawful
representative. If in case I am legally incompetent, I am allowing my lawful representative in my behalf
to have my rights and responsibilities be explained to them in a manner of language and/or dialect
spoken and understood by them and that I or my lawful representative was assured that me and/or my
patient’s rights will be protected and I am willing to fulfill my responsibilities with due respect.
 That, I warrant and guarantee my capability to pay all and any expenses in connection with my
and/or my patient’s confinement and the cost of the procedure/s to be performed on me and/or to my
patient, and that I and/or my patient shall not leave the hospital premises without first settling my
accounts and that for the meantime that I could not pay my or my patient’s hospital bill, I shall not deem
my voluntary stay in the hospital as being withheld against my will;

That should I be incapable of paying any further my and/or my patient’s hospital service or
further cost of medicine/s and or procedure/s, I, or on behalf of my patient, expressly consent to be
transferred to a room or ward accordingly as deemed appropriate by the hospital staff and that from the
moment thereof, I shall be responsible for my foods while I and/or my patient is confined in the
hospital;

It is my full understanding that the hospital is the owner of the original copy of the medical
record/s, the ancillary plates, slides, in connection with my confinement, and that shall be responsible
for any and all expenses for the reproduction of any document or record in connection with my and/or
my patient’s confinement and that henceforth, I shall not hold the hospital liable or responsible for
refusing to release a copy of said document or record without having me or pay the cost or expenses for
the reproduction thereof, and that further, I hereby authorize the hospital to release such relevant
information or result/s or copy of any part of my medical/surgical record to my insurer or to
whomsoever is responsible for the payment of my and/or my patient’s hospital bill/s;

I likewise expressly acknowledge that I was advised by the hospital against keeping any cash
and/or valuables inside the room where I am and/or my patient is confined so that otherwise I shall not
hold the hospital and any of its staff responsible or liable for the loss and/or damage thereof;

I expressly acknowledge that everything contained in this document was explained to me in a

language and/or dialect spoken and understood by me and that affixing my signature has been done
freely, voluntarily, and without coercion, and that this document shall bind my heirs, assigns, and
successors and that this document shall prevail over any other existing or future document/s that may
appear the contents which are contrary hereto.

Signature of Patient over Printed Name Signature of Lawful Representative over

Printed Name

Date and Time

Signature of Witness over Printed Name Date and Time