Republic of the Philippines

Province of Cebu
MUNICIPALITY OF SAN REMIGIO
San Remigio Rural Health Unit

San Remigio Rehabilitation Center (SRRC)

In partnership with Projects Abroad Philippines, Inc.

PATIENT’S INFORMATION

Last Name First Name Middle Name

Date of Birth (mm/dd/yy) Marital Status  M  S  W Gender:  Male  Female 1X1 Picture

ADDRESS House No. Purok/Barangay Municipality/City

State/Country Zip Code Contact No.

Referring Physician Date of Referral Medical diagnosis upon admission

Brief description of patient’s condition/functional status upon admission

EMERGENCY CONTACT
Responsible party/Guarantor e.g. SO, parent/guardian if minor patient

Last Name First & Middle Name Relation to the patient

ADDRESS House No. Purok/Barangay Municipality/City

State/Country Zip Code Contact No.

AUTHORIZATION FOR CARE/INFORMED CONSENT

I/we hereby authorize to receive care at San Remigio Rehabilitation Center. I/we understand that receiving physical
rehabilitation care may involve stress of musculoskeletal tissue that may cause soreness. Additional risks include, but are not
limited to cardiovascular, muscle, ligament, joint, or disc injury. Symptomatic aggravation of my current condition is possible.
Furthermore, I/we understand that the provider may need to perform mobilization technique, manipulation technique, massage
technique, manual traction, distraction, and other movement modalities and services that may produce brief (several days)
soreness and discomfort. It is my/our responsibility to communicate any difficulties that I/we are having during treatment or any
medical or activity changes to my/our provider.

By signing below, I certify that the above information is true and correct to the best of my knowledge and acknowledge consent
with full awareness of the nature and risks of the evaluation and treatment program.

Patient’s Signature Over Printed Name Witness’ Signature Over Printed Name
Date & Time:______________________ Date & Time:______________________

For a minor or an adult who is physically or mentally incompetent, the responsible party/relative will sign. Provide reason the
patient cannot sign:
_________________________________________________________________________________________________________
_________________________________________________________________________________________________________

Relative’s Signature Over Printed Name Witness’ Signature Over Printed Name
Date & Time:______________________ Date & Time:______________________

1
 AUTHORIZATION FORM FOR USE OF PHOTOGRAPHS/ SUCCESS STORIES IN PUBLIC RELATIONS
AND MARKETING ACTIONS PHOTOGRAPHY CONSENT FORM/RELEASE

I, (patient’s full name) _____________________________________, hereby grant permission to San Remigio Rehabilitation
Center representatives, to take and use: photographs, video, and/or digital images of me for use in news releases and/or
educational materials. These materials may include printed or electronic publications, Web sites or other electronic
communications. I further agree that my name and identity may be revealed in descriptive text or commentary in connection
with the image(s). I authorize the use of these images without compensation to me. All negatives, prints, and digital
reproductions shall be the property of San Remigio Rehabilitation Center.

Thank you very much.

CEBUANO
Ako si, (kompletong pangalan sa pasyente) _____________________________________, naghatag og pagtugot sa San Remigio
Rehabilitation Center, nga magkuha ug mogamit og mga litrato, video ug/o mga digital nga mga imahe nako alang sa paghimo o
pagpagawas og news ug/o mga materyal alang sa edukasyon. Kini nga mga materyal mahimong giimprinta o electronic nga mga
publikasyon sa web sites ug uban pa nga electronic communication. Mouyon usab ako nga ang akong ngalan ug identidad
mahimong ipadayag sa deskriptibo nga teksto o komentaryo kalabot sa mga imahe. Gipasaligan nako ang paggamit sa kini nga
mga imahen nga wala’y bayad kanako ug ang tanan nga mga digital nga mga kopya niining mga imahen mahimong kabtangan sa
San Remigio Rehabilitation Center.

Daghang salamat.

Signature of Subject Over Printed Name Witness’ Signature Over Printed Name
Date & Time:______________________ Date & Time:______________________

RELEASE FOR MINOR CHILDREN AND ADULT WHO IS NOT

PHYSICALLY AND/OR MENTALLY INCOMPETENT

I, (responsible party’s full name) _________________________________________, parent or official guardian, significant other
of (patient’s name) _______________________________, hereby grant permission to San Remigio Rehabilitation Center
representatives, to take and use: photographs, video, and/or digital images of my child for use in news releases and/or
educational materials. These materials may include printed or electronic publications, Web sites or other electronic
communications. I authorize the use of these images without compensation to me. All negatives, prints, and digital
reproductions shall be the property of San Remigio Rehabilitation Center.

Thank you very much.

CEBUANO
Ako si, (kompletong pangalan sa responsableng tagtungod) _____________________________________, ginikan o opisyal nga
tagtungod ug tigbantay ni (kompletong pangalan sa pasyente) _______________________________, naghatag og pagtugot sa
San Remigio Rehabilitation Center, nga magkuha ug mogamit og mga litrato, video ug/o mga digital nga mga imahe nako alang
sa paghimo o pagpagawas og news ug/o mga materyal alang sa edukasyon. Kini nga mga materyal mahimong giimprinta o
electronic nga mga publikasyon sa web sites ug uban pa nga electronic communication. Mouyon usab ako nga ang akong ngalan
ug identidad mahimong ipadayag sa deskriptibo nga teksto o komentaryo kalabot sa mga imahe. Gipasaligan nako ang paggamit
sa kini nga mga imahen nga wala’y bayad kanako ug ang tanan nga mga digital nga mga kopya niining mga imahen mahimong
kabtangan sa San Remigio Rehabilitation Center.

Daghang salamat.

Signature of Responsible Party Witness’ Signature Over Printed Name

Over Printed Name Date & Time:______________________
Date & Time:______________________