Republic of the Philippines

ISABELA STATE UNIVERSITY

COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

INFORMED CONSENT FOR ADMISSION OF PERSON UNDER

INVESTIGATION (PUI) AND CONFIRMED/ POSITIVE COVID-19 PATIENT

I, _______________________________________, _____ years of age and a resident of

__________________________________ hereby voluntarily, knowingly and freely consents for myself OR for my MINOR
patient, __________________________________ for Person Under Investigation (PUI) /COVID-19 POSITIVE ADMISSION.

I fully understand that I shall not hold any of the physicians and hospital staff LIABLE for any adverse results of the
treatment to myself OR to my minor patient. I fully know that the physicians and medical staff shall exert their utmost
capacity and observe due diligence in delivering the necessary and proper medical treatment to myself OR to my minor
patient.

I also fully understand and voluntarily agree with the following guidelines to be implemented by ISABELA STATE
UNIVERSITY MEDICAL CENTER exclusively for PUI/COVID-19 patients in accordance and with due compliance with existing
health regulations and strict policies formulated by the Department of Health (DOH), to wit:

NO WATCHER/VISITOR POLICY
The undersigned agrees to comply with the protocol implemented by the management that visitors or watchers will not be
permitted to enter the patient’s room/isolation area during the period of treatment and during the recovery period and up
to the time the patient shall be cleared by the attending physician to be available for visitation and/or discharge.

TELEMEDICINE
The undersigned is well informed that for patients that are diagnosed as Person Under Investigation (PUI)/ COVID-19
positive, monitoring by physician and hospital staff shall be through telemedicine to minimize close contact in order to
prevent the risk of transmission and the spread of the virus. Telemedicine means the exchange of medical information from
one location to another using electronic communication, which improves patient health status.

DISCHARGE AGAINST MEDICAL ADVICE

The undersigned agrees that suspected PUI/COVID-19 positive patients shall be discharged only after he or she is tested
twice to be negative to COVID-19 test and/or cleared by the assigned Infectious Control Doctor after the 14-day quarantine
period.

IN WITNESS WHEREOF, I have hereunto set my hand this ______day of ________, 20___ in the presence of two
witnesses at San Fabian, Echague, Isabela.

_________________________________________________
Signature over Printed Name of Patient/Person Giving Free Consent
__________________________________
Relationship to Minor Patient (if applicable)

I hereby attest to the fact that I have fully explained this Informed Consent Form to the above-named patient OR to
the parent or guardian of the minor patient giving his or her consent in the dialect or language which he or she fully
understands and that he or she fully understood its contents before he or she affixed his or her signature.

________________________________
Signature over Printed Name
of the Nurse-on-Duty
____________________
Date Signed

Signed in the Presence of:

_____________________________ ___________________________
Signature over printed name Signature over Printed Name
of another Nurse-on-Duty of a patient’s relative
 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

ADMISSION AGREEMENT AND TREATMENT CONSENT

CONSENT FOR TREATMENT: The undersigned, knowing that the Patient is suffering from a condition requiring hospital care,
diagnostic, medical, anesthetic and/or surgical treatment, hereby voluntarily consent to and authorize the rendering of hospi tal
care and services, including but not limited to diagnostic procedures, intravenous feedings, injections, transfusions, intubation,
medical, anesthetic and/or surgical procedures which may be performed on the Patient. The undersigned, also agrees to indicat e
the name of the Patient in the listing of Facility Directory for proper identification and safe delivery of care.
HOSPITAL POLICIES: The undersigned agrees to comply with the guidelines, policies, and protocols implemented by the
management such as close drug policy, proper waste segregation, policy on visiting hours, etc.
NURSING CARE: The undersigned understands that the Patient’s care in the Hospital is under the control and direction of the
Patient’s attending physician. The undersigned further understands that the Hospital provides only general duty nursing care, and
agrees that if the Patient needs continuous or special duty nursing care, it must be provided by the Patient or his authorized
representative or his physician and hereby releases the Hospital from any and all liability arising from the fact that such special
and additional care is not provided.
PERSONAL VALUABLES: The undersigned understands that Hospital maintains a safe for safekeeping of money and other articles
of value. The undersigned hereby release the Hospital for any and all liability arising from the loss or damage of Patient’s property,
articles of value, or money not deposited into the custody of the Hospital for safekeeping. Upon Patient’s discharge the undersigned
shall remove from the Hospital all of Patient’s property, including clothing and agrees that Hospital shall not be responsibl e for
loss, damage or disposal of any of the Patient’s property not removed at the time of discharge and thereafter.
PROFESSIONAL CHARGES: If the patient receives X-rays, nuclear medicine, ultrasound examinations, anesthesiology services, or
specialized laboratory testing while hospitalized, the Patient will receive a bill from the Hospital and a separate bill for the
professional component.
FINANCIAL AGREEMENT AND AUTHORIZATION: In consideration of the services to be furnished to the Patient, and the food and
supplies to be provided by the Hospital, the undersigned jointly and severally agrees whether he signs as agent, authorized
representative of the Patient, or as the Patient, that the undersigned assumes full responsibility for and agrees to pay all costs,
charges and expenses furnished to the Patient by the Hospital. The obligations of the undersigned and the Patient are the dir ect,
primary and solidary obligations of the undersigned to the Hospital. No extensions or enforcement delays which may occur shall in
any manner release the undersigned. The obligations of the undersigned hereunder shall be in addition to all other remedies of the
Hospital against Patient. If the undersigned defaults in any of the obligations to the Hospital, the balance of the account t hen
outstanding shall, at the Hospital’s election, without notice or demand, become immediately due and payable. The undersigned
promises to pay all costs, including reasonable attorney fees, incurred by Hospital in the enforcement of the obligation to the extent
permitted by law. I consent to be contracted by regular mail, by email or by telephone (including a cell phone number) regarding
any matter related to the above referenced account by the Hospital, its successors or assigns. This consent includes any updated
or additional contact information that I may provide and includes contact that employs auto-dialer technology and/or pre-recorded
messages.
RESPONSIBILITY ON ROOM CONTENTS AND ACCESSORIES: The undersigned agrees to take good care of all contents, accessories
and features of his assigned room or ward and take full responsibility for and agrees to pay all cost, charges and expenses for any
damages or repair throughout occupancy.
OPPORTUNITY TO AGREE OR TO OBJECT: Patients have the right to have the opportunity to agree or to object to the use and
disclosure of their Protected Health Information in facility directories and for notification. The undersigned understands this right
and makes the following choice:
____ The undersigned agrees to the use and disclosure ____ The undersigned objects to the use and disclosure

____________________________________________________________ __________________ ______________

Signature of Patient or Authorized Representative over Printed Name Date Time

Relationship to patient if signature is other than patient: ______________________ Contact Number: ______________________
Address: _________________________________________________________________________________________________

If the patient is a minor or is otherwise unable to sign consent because of physical disability or incompetence, complete the
following: The Patient is unable to consent because: ______________________________________________________________
________________________________________________________________________________________________________
Signed in the presence of:

________________________________________
Signature over Printed Name
 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

CONSENT TO CARE

I have hereby authorized Dr. __________________________________ and any of the staff of ISABELA STATE UNIVERSITY
MEDICAL CENTER to perform treatments and procedures they deem necessary for my care.

Pinahihintulutan ko si Dr. ___________________________________ at ang sinuman sa pangkat ng mga Manggagamot o mga

kawani ng ISABELA STATE UNIVERSITY MEDICAL CENTER na maaatasang gumamot sa akin upang magsagawa ng mga
paggamot at mga pamamaraan na itinuturing nila na kinakailangan para sa aking pangangalaga at paggaling.

The Attending Physician, as well as Santiago Medical City and its staff, shall not be held responsible for any untoward complications
resulting to death or other unusual, unforeseen and unexpected incidents, provided they have not been negligent and have
expressed utmost professional diligence in patient care.

Hindi ko binibigyang sala at hindi ko pananagutin ang nasabing gumamot na Doctor sa akin, gayundin ang Isabela State University
Medical Center at ang mga tauhan at kawani nito, kung magkaroon ng kumplikasyon o hindi inaasahang pangyayari na
magreresulta sa kamatayan o iba pang mga hindi pangkaraniwang o hindi inaasahang pangyayari, basta’t hindi ito dahil sa
kanilang kapabayaan at basta’t ginawa nila, bilang manggagamot ang lahat ng kanilang makakaya at kanilang kaalaman para
sa pangangalaga sakin bilang pasyente.

________________________________ ________________________________
Signature of Witness Signature of Patient or Authorized
Lagda ng Saksi Representative over Printed Name
Lagda ng pasyente o representative

___________________ ___________________
Date Date
 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

ADMISSION HISTORY AND PHYSICAL EXAMINATION

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

DISCHARGE / CLINICAL SUMMARY

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

NURSE’S MONITORING SHEET

Other
s
 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

VITAL SIGNS SHEET

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

DOCTOR’S ORDER SHEET

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

MEDICATION ADMINISTRATION RECORD

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

MEDICATION ADMINISTRATION RECORD

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

INTRAVENOUS INFUSION MONITORING SHEET

 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

NURSE’S NOTES
 Republic of the Philippines
ISABELA STATE UNIVERSITY
COLLEGE OF NURSING
San Fabian, Echague, Isabela 3309 Philippines
Tel Nos.: (078) 333-9999

LABORATORY RESULT SHEET