Informed Consent

PTSI- EVCCD BGM

AGREEMENT I,____________________,____years old, single/married __________________hereby depose and say:

and

a

resident

of

1. That I am desirous of availing the services of the PTSI –EVCCD ,Tacloban City. 2. That I was given a briefing/orientation regarding my responsibilities and obligations as a TB-DOTS patient on_____________________by BHELL G MENDIOLA 3. That I have chosen_______________,___________________(relationship to patient) As my Treatment Partner, who consented on his/her own free will, for the duration of my Treatment from____________to _____________: 4. That my Treatment Partner and myself were given relevant and appropriate health teaching and after which we have fully understood our responsibilities, to wit: a. To appear at the DOTS Clinic for the weekly visit to be done every_______ Until the end of the treatment period: b. To submit a sputum specimen for the follow-up sputum microscopy to be done On the following dates: i. 1st________ ii. 2nd________ iii. 3rd ________ 5. That I have fully understood that the anti-TB medicines that I may avail are free of charge, however, I have to pay for the other services rendered and supplies used in the course of my treatment , but not limited to the following: a. Sputum microscopy(follow-up) Php 40.00 per smear b. Medical consultation(as needed) 100.00 per consult c. Chest X-ray 155/175 per exposure d. Sputum microscopy 100.00 per set 6. That I hereby impose upon myself the duty to update the DOTS Clinic regarding my condition and /or whereabouts for the duration of the treatment: and 7. That I hereby give permission to PTSI-EVCCD Clinic the right to course follow-up visits through the Barangay Health Station/Rural Health Unit of ___________________where I permanently reside. 8. These promises I make upon myself on my own free will.

In witness whereof I hereby affix my signature below this_____ day Of_____________in the City of Tacloban. ______________________ _________ (Patient’s Signature Over Printed Name) Contact No.______________________ Complete Address_________________ ______________________ _________ (Sketch at the back)

PhilHealth (M)(D) Validity____________ Contact Person, if any_______________ Tel.No./Mobile Phone_______________ WITNESS: _________________________ _____________________________ Treatment Partner (Signature Over Printed Name) Over Printed Name)

(Signature