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Out $*da, a$ ffauc*w*$a.fifuap;ta.L, Jm,c.
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'lrilii
], CKC Ccmpr:u:ed, Magsaysay Bouievard
;r,r:l
Calbayog City

CONSENT T$ CARE
I h*reby authsrize Dr. and the sta{f of OtiJt
I--ADY OF PARZIUNCOI,A HGSPII'AL", IHC. to prforrn treatrnent and procerJures deemed
necessary for care,

I also give authority for the hospital to supply nc&sssary informati+n from nry medical
records tc my insurance representativc or to my attorney in fact"

Signahre or Thurabmark of Patient

or Ferso{r grving fte* cocss[t

IL{FORMaD CpN_SENT qOB SURSipRY IANSSTHESIA OB STHER".P$SCSJ}URE

[" years of age marrie#sfuIgle/ widow hereby

give consenr m eJ; ;ffi for . , *_- *:-------**_ - . , who is rny

thc procedure/op€{ailon anesthe$ia hereunder stat€d after there have
Rddl4,ee,Pdt{Ett
been fully explained !o me by my doctor concerned ooncluding the risk involve and their
altrnative procedtres

hoeedure /Operation I Anesthesia Explaindby:

I, also congsat to proper dispasal by auth*rities of Our l,ady *f Poreiuucola Hosgital, [nc. cf
whatcver tissues may be remroved from nnyself / the paticnt"

I, also *ons$ril to the taking of photography in the tissue of &is treaunent of operation for tbe
p$rFose of advancing medical knowledge.

' IN WITNESS HEREOF [, hcreunto set my hand this day of

20 at

IN THE PRESENCE OF

Witness
Signature or Tliumbrnark of
prtient t:r p€rson grving free cc*sent.
latergeter

CUh'ICAT qHJ?&T 4
s *. car*m.i'$.q HospITAL r H v$J u ilttq g,p,ryr*sp.qH qs'r
pATM{r'ShTAilffi
ATTH{ShI# P.$YSI#IA}T:
Fhyxiciarr'u CIrder / Signafrre
 &rx #adB *$,Pwx.*,ww8x -ffiaptra&, .#**
CKC C*rpund s{ag**y*ay S*uievsrd
CalbayogCiry

rFr.resYEl{,pu$,f'r{ils sI"gw $rffi qg

Hams Age:._=-* Pbysician: Hm: S*d?{*.

EV Si{*/Remsrkr

tL rnekO6arf*t\ u"rO ; L#
pL?+L ( gooul-

CC Fms tl
-,,,.. : $T. CAPTITLU,S HT}$EITAtr"
AirportRoad, 6710 Calbayog City
TeltFax {OES) 0116f,4

HospitalNo.

Ward / Room

{Centigrade)

n.M.. r P.tl- P.rtr. I A.tr. p.M, I A.H, p,n. ir. r P.l*.

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$T. CAffiItlUS HT}SBITAL
*irportRoad, 6710 Calbaycg City
TetiFax {055) 9116$4

Ase

Given Name Sx- Ward / Room i

GRAPHIS CHABT {Centigrade}

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