Republic of the Philippines

STA. BARBARA VILLAS 1 HOMEOWNERS ASSOCIATION INC.

SBV1HOA Health Center
Admin Bldg., Phase IV, Sta. Barbara Villas 1, Silangan, San Mateo, Rizal
Tel No: 734-33-24

WAIVER AND CONSENT FORM

I, _________________________, ___ years of age, residing at Blk__, L__, Ph__, Sta. Barbara Villas 1, San Mateo,
Rizal am willing to undergone _________________ despite _________________________________________________.
I acknowledge that:
1. The attending physician/nurse have explained my physical and medical condition, the proposed action of the said
procedure and the risks it could take.
2. I understand the risk of the administration of the vaccine/s, including the risks that are specific to me and the likely
outcomes.
3. I was able to ask questions questions and raise concerns with the attending physician/nurse about my condition,
the procedure and its risks. My questions and concerns have been discussed and answered to my satisfaction.
4. I understand that the attending physician/nurse and the SBV1HOA Health Center free and harmless for any
claims, demands or suits for damages from inquiry and complications resulting from the act, omission, or fault of
the attending physician/nurse in the performance of his/her professional duty prior and during the
_________________.
On the Basis of the above statement:
I REQUEST TO HAVE _____________________ TO ME BY ATTENDING PHYSICIAN/NURSE.

____________________________________
Patient Signature over Printed Name/Date