PATIENT PROFILE AND CONSENT FORM
LAST NAME:
FIRST NAME:
MIDDLE NAME:
SUFFIX (JR., SR., III, etc.): BIRTHDAY: MM DD YYYY
ADDRESS: HOUSE NO. LOT NO. BLOCK NO.
STREET NAME
VILLAGE/SUBDIVISION/BARANGAY
CITY/MUNICIPALITY
GENDER: CONTACT DETAILS:
_______ MALE _______ FEMALE E-MAIL ADDRESS _____________________________________
NATIONALITY _____________________________________ HOME PHONE _____________________________________
CIVIL STATUS _____________________________________ WORK PHONE _____________________________________
OCCUPATION _____________________________________ MOBILE PHONE _____________________________________
EMPLOYER/CORPORATION ______________________________________________________________________________________
PERSON TO NOTIFY IN CASE OF EMERGENCY: _________________________________________________________________
RELATIONSHIP __________________________________ CONTACT NO. ____________________________________
Private Patients:
I will pick up the results myself Please send results to the e-mail address supplied above.
_______ A representative with an authorization letter ________ Please send results to Makati LGU for Sanitary Permit
and ID will pick up the results.
I understand that the security and reliability of obtaining the results through means other than personal pick-up cannot be
guaranteed. I hereby hold FORTMED, its officers, directors, stockholders, employees, consultants, and doctors free from all claims,
suits, charges, fees, damages, or liabilities arising from or connected with the release of the medical records by these means .
Corporate/HMO/Insurance Patients:
Results of medical tests required by my employer/potential employer/insurance company may be sent to them directly as instructed
in the LOA/Referral Slip and/or to the local government unit (LGU) for purposes of the employer’s application for Sanitary Permit. I
hereby authorize FortMED to disclose to my employer/potential employer/insurance company and/or to Makati LGU, results of the
tests and procedures undertaken. I hereby hold Fortmed free from claims and damages arising from such disclosure.
By submitting this form, I hereby consent and confirm to the lawful collection, use, disclosure, retention, and disposal of FortMED of
the personal and sensitive personal information in accordance with the Privacy Policy of FortMED, accessible through
http://www.fortmed.org/web/patient-privacy/.
_____________________________________________ ________________________________
Patient’s Signature over Printed Name Date
FORTMED MEDICAL CLINICS
CONSENT FORM
In compliance with Republic Act No. 10173, otherwise known as the “Data Privacy Act”, Fortmed Medical Clinics (“FORTMED”) seeks your consent
to collect, process, store, and use your personal data ((age, residence, employment details, HMO details, Philhealth details, contact details, medical
history), results of physical and diagnostic examination such as, but not limited to complete blood count, blood chemistry, urinalysis, fecalysis, chest
x-ray, ECG, pap smear, drug test and any other information related to your visit to FORTMED, as part of your consultation, diagnostics, pre-
employment physical examination, annual physical examination, or executive check-up (“PPE/APE/ECU”), as a private individual or as an
employee/officer of _________________________________________________________________ (the “Corporation”).
FORTMED intends to collect your personal information to provide its service, which information shall be used and processed by all personnel,
consultants and third-party service providers connected with FORTMED. After every examination, FORTMED will generate reports from the data
collected which FORTMED will send to you, the Corporation, or to third party you authorize it to send to. For this purpose, your information will be
stored by FORTMED for a period of ___ years, without prejudice to your rights to reasonable access to, upon demand, and correction of your
personal information, as well as your right to lodge a complaint before the National Privacy Commission, under Section 16 of the Data Privacy Act.
(For more information on your rights, please see https://privacy.gov.ph/know-your-rights/). FORTMED implements measures to protect the personal
information you provide, in accordance with its privacy policy, which the Corporation likewise adopts. (For more information, please see
https://www.fortmed.org/web/wp-content/uploads/Fortmed-Privacy-Policy-03.08.2022.pdf). Should you wish to access, correct or update the
personal information you have provided, or if you have any further questions about the use of your personal information, please write us at
dataprotection@fortmed.org.
I have read the above information, including FORTMED’s privacy policy and the Data Privacy Act, and understand the reasons for the collection of
my personal information and the ways the information may be used and disclosed, and I agree to said usage and disclosure.
I understand that it is my choice as to what information I provide, and that withholding or giving false information might act against the best interests
of my medical assessment/diagnostics.
I understand that the information I provide will be processed and sent to the Corporation for whatever legitimate purpose it may serve and/or to the
local government unit through its portal for purposes of the Corporation’s application for Sanitary Permit.
I hereby authorize FORTMED to release all medical records and related documents and information derived from diagnostics, laboratory services
and medical consultation with the FORTMED including a summary thereof, for whatever legitimate purpose it may serve. In the same manner, I am
giving the Corporation full and unrestricted access to my personal data.
I hold FORTMED, its officers, directors, stockholders, employees, consultants, and doctors free from all claims, suits, charges, fees, damages, or
liabilities arising from or connected with the release or disclosure of the medical records. l also hold FORTMED, its officers, directors, stockholders,
employees, consultants, and doctors free from all claims, suits, charges, fees, damages, or liabilities from any hiring decision made by the
Corporation.
I am aware that I can access my personal and diagnostic/treatment information upon request and if necessary, to correct information that I believe
to be inaccurate. Further, I understand that if, in exceptional circumstances, access is denied for any legitimate purposes, the reason for this and
possible remedies will be made available to me.
__________________________________________ _____________________________
Signature over Printed Name Date
Confidentiality Notice: FORTMED will not disclose any information obtained in the conduct of the PPE/APE/ECU, except as otherwise provided
herein, subject to the provisions of the Data Privacy Act. Further, FORTMED guarantees that information that can be identified with you will remain
confidential and will be disclosed only with your permission or as required by law.
Disclaimer: If you have any question regarding results, a medical condition or any of the data contained therein, you may seek a second opinion
from your physician or other qualified health provider. It is hereby understood that FORTMED shall not be held liable for any injury or damage arising
from laboratory results and diagnosis it issued. Neither shall FORTMED be liable in any way for the hiring/employment decisions of the Corporation.
Waiver: I certify that the information I provided in the Patient Profile and Consent Form and the statements made by me in answer to the questions
in the PPE/APE/ECU are true and correct to the best of my knowledge and belief. I understand that I am required to complete all medical test stated
in the LOA/Referral Slip within seven (7) days at Fortmed Clinics. I understand that my failure to complete these tests may result in delayed and
incomplete medical files and inaccurate medical assessment.
__________________________________________ _____________________________
Signature over Printed Name Date
