WAIVER FORM

I, __________________________, of legal age, single/married and a resident of

_______________________________________, do hereby agree and undertake the following,
to wit:
1. That I have been counselled, advised and conducted interview by
_____________________ regarding my medical history and health status.
2. That I obtained the services of ______________________ which is/are
_____________________________.
3. That in case I will not follow the advise of any of the personnel of
______________________, I shall assume any and all risks and shall take full
responsibility for myself and my actions and shall further hold free and harmless
_________________ and its officers, agents, and employees against all losses, damages,
or liabilities resulting from claims, suits, and actions for injuries to persons (including
death) to the extent caused by or arising out of any negligent, wanton or intentional act or
omission on my part regarding my procedures.
4. That I have read and understood the foregoing and acknowledge my consent to this
Waiver by signing hereof.

IN WITNESS WHEREOF, I have hereunto affixed my signature this_______ day of

____________, 2022 at Kawit, Cavite.

__________________________
SIGNATURE

Witness/es:

1. ______________________________ 2. ______________________________