Republic of the Philippines

Bangsamoro Autonomous Region in Muslim

Ministry of Health
Datu Odin Sinsuat District Hospital
Dalican, Datu Odin Sinsuat, Maguindanao

DOSDH – CIF WATCHER WAIVER FORM

Date: ________________

I, ___________________________________, ________ years old, hereby request to be the

(Name of Watcher) (Age)
watcher of patient Ms. /Mr. ______________________________ who is my
(Name of Patient) (Relationship to Patient)
________________. The patient is a __________________ case for Covid-19 and is admitted
(Covid-19 Case Classification)
for quarantine / isolation purposes in Datu Odin Sinsuat District Hospital – Covid-19

Isolation Facility.

I have been thoroughly informed of the risks and consequences of this decision and

will not hold the staff nor the management responsible / liable for all my undertakings

while I am in the facility. Rest assured that I will be strictly observing all the stated

quarantine / isolation protocol set forth by the facility and will cooperate to the

treatment plan of my patient.

The content of this form was explained to me in a language / dialect I understand and

its effect shall only cover the time of my admission to the date of my discharge from

the facility

WATCHER

(Signature over printed name)

WITNESS
(Signature over printed name)