Republic of the Philippines

Department of Health
Municipality of Pugo
RURAL HEALTH UNIT

Consent to Contact

I, authorize the Rural Health Unit of Pugo

staff to contact Tel/Mobile # ______________________, Relationship
____________________, for further information that will be helpful for my recovery
treatment.

I understand that my records are protected under the Rural Health Unit of Pugo
Confidentiality Rule and cannot be disclosed without my consent. I also understand that I
may revoke this consent any time.

I hereby acknowledge and declare the terms of this authorization to gathered

information are fully understood by me.

(PATIENT PRINTED NAME OVER SIGNATURE)

Witness/es:

(CLINICIAN PRINTED NAME OVER SIGNATURE)

(CLINICIAN PRINTED NAME OVER SIGNATURE)

DATE

This form is originally owned by the DDAPTP for the use of Treatment
and Rehabilitation Centers DOHSFLUTRC-FM-HIM-CTC-01

ITRMC Compound, Parian, City of San Fernando, 2500 La Union

Trunk Line No.: (072) 687-8070 to 79 · Direct Line No.: (072) 619-6272 · Mobile No. +63 9190659468
Email Address: doh.sflutrc@gmail.com · FB Page: @DOHSFLUTRC