Province of Benguet

Municipality of Itogon
Municipal Health Services Office

PATIENT’S CONSENT
A. For Procedure and Treatment
(IN ENGLISH) This is to certify that I __________________________________ submit myself
voluntarily to prescribed _______________________ treatment/procedure by the physician/health
care provider. I have been informed of my Rights and Responsibilities as a patient, the primary
health care rules and regulations, of which I have read a copy.

(IN TAGALOG) Ito po ay nagpapatunay na ako ____________________________ ay kusang

pumapayag na mabigyan ng ________________________ na nararapat na lunas at
pamamaraan naaangkop sa aking medical na kalagayan. Ipinamaalam sa akin ang aking mga
Karapatan at Responsibilidad bilang pasyente, ang pangunahing patakaran sa pangangalaga ng
lakusugan at regulasyon na nabasa ko na.

B. For Patient’s Medical Record

(IN ENGLISH) I have read and understood the Patient’s Information after I have beenmade aware
of its contents. During an informational conversation. I was informed in a very comprehensible
way about the essence and importance of the Integrated Clinic Information System (iCLinicSys)
by the Health Center representative. All my questions during the conversation were answered
sufficiently and I have been given enough time to decide on this.

(IN TAGALOG) Aking nabasa at naintindihan ang impormasyon ng Pasyente matapos ako’y
bigyang kaalaaman ng mga nilalaman nito. Sa isang pag-uusap kasama ang kinatawan ng Health
Center, Ako aybinigyang paunawa nang mahusay tungkol sa kakayahan at kahalagahan ng
Integrated Clinic Information System (iCLinicSys). Lahat ng aking mga katanungan sa panahon
ng pag-uusap ay nasagot ng sapat at ako ay binigyan ng sapat na oras upang magpasya nito.
Higit pa rito, pinapayagan ko ang ____________________________ Health Center upang i-
encode ang mga impormasyon patungkol sa akin at ang mga nakolektang impormasyon tungkol
sa mga sintomas ng aking sakit at konsultasyong kaugnay ditopara sa nasabong information
system.
Nais kong malaman at maipaalam ang aking pahintulot sa ___________________ Health Center
anumang oras na walang ibinibigay na dahilan at walang kinalaman sa anumang kawalan para sa
aking medical na pagpapagamot.

________________________________ ______________________________________________
NAME & SIGNATURE OF PATIENT/DATE NAME & SIGNATURE OF HEALTH CARE REPRESENTATIVE/DATE