SAN PADRE PIO BIRTHING HOME AND POLYCLINIC

105 DON ANTONIO BAUTISTA ST. SAN AGUSTIN, CITY OF MALOLOS, BULACAN
09227188792

RELEASE OF RESPONSIBILITY FOR ERRONEOUS ENTRY ON BIRTH CERTIFCATE

NAME : ____________________________________________________________________
FIRST MIDDLE LAST

DATE OF BIRTH : _______________________________ SEX : __________________________

I hereby certify that the Birth Certificate of my baby has been presented to me for final review and correction
of any erroneous entry typographical or otherwise.

I therefore assume full responsibility for any correction that has to be made after the Birth certificate has been
registered.

I hereby release San Padre Pio Birthing Home & Polyclinic from all liabilities of whatever nature which may
arise from the registration of the Birth with erroneous entry.

_______________________________
FATHER / MOTHER
PABATID!

Ito ay katunayan na ako si ____________________________, ______ taong gulang na

nakatira sa _________________________________________ ay nagbibigay pahintulot sa SAN PADRE PIO BIRTHING
HOME AND POLYCLINIC para sa karampatang gamut at ano pa mang kakailanganin para sa aking maayos na
panganganak na hindi sasakupin o nasasakop ng serbisyo ng PHILHEALTH, ay aking babayaran at sasagutin.

QTY PARTICULARS AMOUNT TOTAL

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PANGALAN AT LAGDA NG PASYENTE PETSA