DATA PRIVACY CONSENT FORM

I certify that all information given is true and correct. I hereby authorized AHSCI to collect, record, update,
use, disclose, store, block, erase or destruct my personal data as part of my personal information for purposes
of my medical treatment and services, billing processing, and other purposes necessary for AHSCI to
continue its operations and as may be required for legal, regulatory or legitimate business purposes.

I affirm my right to be informed, object to processing, access and rectify, suspend or withdraw my personal
data, and be indemnified in case of damages pursuant to the provisions of the Republic Act No. 10173 of the
Philippines, or Data Privacy Act of 2012 and its Implementing Rules and Regulations.

Signature over Printed Name Date