I understand and agree to the following:

Medical Interview and Examination

I consent to medical history taking, physical examination, and diagnostic procedures necessary for my care
I will provide truthful and complete information about my health condition
I understand that I can ask questions at any time during the consultation

Treatment and Medications

I authorize the physician to prescribe and administer medications appropriate for my condition
I understand the purpose, expected beneﬁts, and possible side eﬀects will be explained to me
I will inform the doctor of any allergies, current medications, or health conditions
I understand that separate consent will be required for any procedures beyond routine consultation (e.g., minor surgery, injections, wound care)

Referrals and Laboratory Tests

I consent to referrals to specialists or diagnostic facilities if medically necessary
I understand that laboratory tests, imaging, or other diagnostics may be recommended
I am responsible for costs of external laboratory tests and specialist consultations

Limitations of Medical Practice

I understand that medicine is not an exact science and no guarantees are made about treatment outcomes
The physician will exercise professional judgment based on current medical knowledge
I will be informed of any unexpected ﬁndings or need for additional treatment

Financial Responsibility

Patient's Rights and Responsibilities

I have been informed that I have the right to:

Receive quality care without discrimination
Receive clear explanations about my condition and treatment in a language I understand (Ilocano / Tagalog / English)
Privacy and conﬁdentiality of my medical information
Refuse any diagnostic procedure or treatment
Choose my healthcare provider
Access my medical records

I acknowledge my responsibility to: