Data Privacy Consent
INFORMATION REGISTRATION & GENERAL CONSENT *
TO THE PATIENT/REQUESTOR: YOU HAVE THE RIGHT TO BE INFORMED ABOUT YOUR PERSONAL DATA WHICH
WILL BE ENTERED INTO OUR SYSTEM AND THE PURPOSE(S) FOR WHICH THEY WILL BE PROCESSED. KINDLY
READ ALL THE INFORMATION ON THIS FORM BEFORE ACCOMPLISHING AND SIGNING IT. IF YOU HAVE
QUESTION(S) OR CONCERN(S), PLEASE FEEL FREE TO ASK ANY OF OUR STAFF.
I. Consent for Information Registration and Other Data Processing:
1. I certify that the information above are true and correct.
2. In the course of my treatment or availment of other healthcare services, I consent to the processing (collection, recording,
retrieval, use, retention and disposal/destruction) of my personal data, as provided under applicable laws, regulations and
MED’s policies and guidelines. Such personal data are those relevant to purpose of my diagnoses, treatment, availment of
healthcare services and processing of hospital bills, claims, and quality improvement activities for enhancement of patient
care.
3. I consent in making my information available to healthcare team members who are involved in the management of my care
including service providers and partners, and to other applicable parties such as regulatory authorities, like Department of
Health, PhilHealth; my employer, my Health Maintenance Organization (HMO), and/or insurance provider for the payment of
my bills.
4. I am aware of my rights in relation to the Personal Data that may be collected from me and my next of kin/legal
representative, including right to access, correction, and to object to the processing of the same. I may
visit https://www.privacy.gov.ph/know-your-rights for more details of my rights on data privacy.
II. Consent for Procedure(s):
5. I and my immediate family (and/or legal representative) are aware that we will receive education regarding
procedure/treatment to be performed. All my questions and concerns will be addressed to my satisfaction before a
procedure/treatment will be done.
6. I authorize and its staff to perform procedure(s) and treatment(s) necessary. If, during the procedure/treatment, other
condition(s) are discovered, and in the best judgement of my physician or surgeon, require an extension of the original
contemplated procedure or require additional procedure(s)/treatment(s) or test(s), I understand that this will be explained to
me for my concurrence, unless I am not able to express consent and the processing is critical to protect my life and health. I
am also aware that the additional procedure(s)/treatment(s) or test(s) may incur cost that will be added to my bill.
7. I am aware that the practice of medicine is not an exact science and that no guarantee or warranty was made as to the
result(s) that may be derived from this procedure.
8. I understand that a separate informed consent is obtained when the planned care includes surgical or invasive procedure,
anesthesia, procedural sedation, use of blood and/or blood products, or other high risk treatment(s)/procedure(s) and/ or when
data will be used for research.
9. I agree that any cause of action arising from the aforementioned, patient confinement, diagnostic examination and
treatment(s) is filed exclusively in the
I acknowledge that I have read this “Information Registration and General Consent” in a language/dialect that I understand, and I
can clarify with any hospital staff any question. I can also refer ts website at for more details on the Data Privacy Notice.
I acknowledge that this Information Registration & General Consent is valid for five (5) years or as deemed necessary.
_________________________
Signature above printed name
