ACEDDI-04-NSD-053-00

INFORMED CONSENT FOR PROCEDURES

TO WHOM IT MAY CONCERN:

I, ____________________________, ______ years old, married/single/widow/widower, hereby consent to the

(Given Name) (Surname)
(Ako taong gulang, kasal, walang asawa/balo ay pinahihintulutan isagawa
performance upon ____________________________ , who is my ________________, the procedure/operation
(Myself/Name of patient) (Relation)

here understated after these have been fully explained to me by the doctors concerned including the risks involved
and their alternative procedures.

Name of Procedure: Explained by:

(Pangalan ng Operasyon) (Pinaliwanagan)
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________
__________________________ __________________________

I also consent to the proper disposal by authorities of the ACE Dumaguete Doctors Inc. of whatever
tissue may be removed from myself/the patient.

IN WITNESS WHEREOF, I hereunto set my hand this ____day of ___________, 2023 at ______________.

______ ________________________________
Patient’s Signature or “Thumb Mark”
Or that of the Person Legally Responsible

Patient is Minor, aged _____________________________

(Ang pasyente ay menor de edad ____________________
Or is unable to sign because ________________________
(O walang kakayahang pumirma dahil)________________

_________________________________ _____________________________
Relative’s Signature over Printed Name Nurse on Duty
(Lagda ng Kamag-anak) (Nars)