Republic of the Philippines

Province of Ilocos Sur

ILOCOS SUR PROVINCIAL HOSPITAL-GABRIELA SILANG
Vigan city

CONSENT TO SURGERY/ANAESTHESIA

CONSENT TO SURGERY
1. I hereby authorize Dr. ________________________ and the staff of Ilocos Sur Provincial Hospital-Gabriela
Siak palubosal ni Dr. ken daguiti staff ti Ilocos Sur Provincial Hospital-Gabriela
Silang to perform _____________________________ and such additional operations and procedures as are
Silang nga mangaramid (Operation or Procedure) ken aniaman nga operasyon ken “procedures”
Considered necessary on the basis of there being a threat to life found during the course of said operation to
Manpanggep ti pagsyaatan wenno saan nga pagdaksan iti bagi ti pasyente bayat ti pannakaoperami
______________________________________, who is my _____________________________________.
Myself or Name of patient (Nagan ti pasyente) isu nga Relationship (Panakaibagi)

2. The nature and purpose of the operation, the risk involved, and the possibility of complications have been
Iti maited nga pagsyaatan iti operation, ken narisgo nga mapasamanak ken posibilidad nga komplikasyon ket
explained to me, in my dialect or in a language which I understand. I acknowledge that guarantee has been made
naipakaammo iti pagsasao nga naawatak. Awatek nga adda garantisado ken nasyaat
as to the results that may be obtained.
nga resulta na.

_________________________________________ ____________________________________________
Signature of Witness over Printed Name Signature of Patient over Printed Name
or person giving free consent
___________________
Date

This authorization must be signed by the patient or by the next of kin in the case of a minor or where the patient is physically or
mentally incompetent.

Patient if a minor of ______ years.

Patient is unable to sign because ________________________________________________.

CONSENT OF ANAESTHESIA
1. I hereby authorize Dr. ______________________________ and the staff of Ilocos Sur Provincial Hospital-Gabriela
Siak palubosak ni Dr. ken daguiti staff ti Ilocos Sur Provincial Hospital-Gabriela
Silang to give _____________________________ anaesthesia to enable the surgeon to perform operation to
Silang (Spinal, regional, general) pammaturog tapno maaramid ti siruhano ti operasyon kenni
______________________________________, who is my _____________________________________.
Myself or Name of patient (Nagan ti pasyente) isu nga Relationship (Panakaibagi)

2. The nature and purpose of the anaesthesia, the risk involved, and the possibility of complications have been
Iti maited nga pagsyaatan iti operation, ken narisgo nga mapasamanak ken posibilidad nga komplikasyon ket
explained to me, in my dialect or in a language which I understand. I acknowledge that guarantee has been made
naipakaammo iti pagsasao nga naawatak. Awatek nga adda garantisado ken nasyaat
as to the results that may be obtained.
nga resulta na.

_________________________________________ ____________________________________________
Signature of Witness over Printed Name Signature of Patient over Printed Name
or person giving free consent
___________________
Date

This authorization must be signed by the patient or by the next of kin in the case of a minor or where the patient is physically or
mentally incompetent.

Patient if a minor of ______ years.

Patient is unable to sign because ________________________________________________.

NUR 004-0