Republic of the Philippines

Province of Ilocos Sur

Metro Vigan Hospital

CONSENT TO SURGERY

1. I hereby authorize Dr. ________________________ and the staffs of Corpuz Clinical Hospital
(Siyak, Palubusak ni Dr. ken daguiti staff ti Corpuz Clinical Hosspital

to perform_____________________________ and such additional operations and procedures as are

nga mangaramid (Operation or Procedure) ken aniaman nga operasyon ken “procedures”

considered necessary to the basis of there being a threat to life found during the course of said
maipanggep ti pagsayaatan wenno saan nga pagdaksan iti biag iti pasyente bayat ti
operation to ______________________________________ who is my ______________________
Pannakaoperami Myself or Name of Patient (Nagan ti Pasyente isu nga Relationship (Panakaibagi)

2. The nature and the purpose of the operation, the risk involved, and the possibility of
Iti maited nga pagsayaatan iti operasyon, ken narusgo nga mapasamak ken posibilidad nga

complications have been explained to me, in my dialect or in a language which I understand. I

komplikasyon ket naipakiammo iti pagsasao nga naamwak

acknowledge that guarantee has been made as to the result that may be obtained.
awatek nga adda garantisado ken nasayaat 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 is a minor of __________years.

Patient in unable to sign because _____________________________________________________________

CONSENT TO ANAESTHESIA
 Republic of the Philippines
Province of Ilocos Sur
Metro Vigan Hospital

1. I hereby authorize Dr. ________________________ and the staffs of Corpuz Clinical Hospital
(Siyak, Palubusak ni Dr. ken daguiti staff ti Corpuz Clinical Hosspital

to give_____________________________ anesthesia to enable the surgeon to perform operation to

(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 the purpose of the anesthesia, the risk involved, and the possibility of
(Iti maited nga pagsayaatan iti operasyon, ken narusgo nga mapasamak ken posibilidad nga

complications have been explained to me, in my dialect or in a language which I understand. I

komplikasyon ket naipakiammo iti pagsasao nga naamwak

acknowledge that guarantee has been made as to the result that may be obtained.
awatek nga adda garantisado ken nasayaat 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 is a minor of __________years.

Patient in unable to sign because______________________________________________________________