PAMPANGA COVID-19 ISOLATION AND QUARANTINE FACILITY

____________________________________
(Indicate here name of Facility)

CONSENT FORM

Name: ___________________________________ Age: ____________

Nationality: ____________________________ Gender: _______________
Address: _______________________________________________________
Occupation: __________________________ Contact No.: _________________
Emergency Contact Name & No.: _____________________________________

I, the above-named and undersigned, do hereby freely and voluntarily give my

consent to the following (Ako, na nakasaad ang pangalan sa itaas at nakalagda sa
ibaba, ay malaya at kusang-loob na nagbibigay ng aking pag-sang-ayon sa mga
sumusunod):

1. To be admitted at the above-named COVID-19 Isolation and Quarantine

Facility of the Province of Pampanga for a minimum period of fourteen (14)
days. (Na matanggap at ma-quarantine sa nakasaad sa itaas na COVID-19
Isolation and Quarantine Facility ng Lalawigan ng Pampanga ng hindi bababa
sa labing-apat [14] na araw);

2. In giving my consent, I am fully aware of the amenities and provisions of the

said COVID-19 Isolation and Quarantine Facility (Sa aking pag-sang-ayon,
mulat ako sa mga kagamitan, kasangkapan at iba pang probisyon ng
nasabing COVID-19 Isolation and Quarantine Facility); and (at),

3. I am aware of my possible transfer to a hospital referral facility of the Province

of Pampanga and I also consent thereto if the same be deemed necessary by
Pampanga and/or its medical personnel (Batid ko na maaari akong ilipat sa
mga hospital referral facility ng Lalawigan ng Pampanga at ako ay sumasang-
ayon rin dito kung kinakailangan ayon sa patakaran ng Pampanga at ng mga
doktor at medikal na kawani nito).

4. I will abide with the rules and regulations of the CoVid 19 isolation facility, and
that I am aware that appropriate sanctions will be carried out with any breach
of the facility’s policies.

5. I will respect the privacy of other patients during my stay in the Pampanga
Isolation Facility.

6. I will not in any manner malign the isolation facility in any means of
communication or publication such as but not limited to the social media.

IN WITNESS WHEREOF, I have set my signature below (BILANG PATUNAY,

aking inilalakip ang aking lagda sa ibaba.

________________________________ ________________
(Patient - Printed name and signature) Date (Petsa)
(Parent/s or Guardian if Patient is a minor)
(Pangalan at Lagda)
CHECKLIST:

Please be sure to bring the listed items before your admission to any of
the isolation facilities managed and operated by the Provincial
Government of Pampanga, to avoid any inconvenience or delay in your
scheduled admission for isolation.

 Copy of PCR Result

 Consent Form
 Clothes good for at least 14 days
 Maintenance Medications for 21 days
 Drinking Tumbler (for hot & cold)
 Spoon, Fork, Plate – Reusable
 Towel
 Rubber Slippers
 Toiletries (toothbrush, toothpaste, soap, shampoo)
 Reading Materials, etc.