Scribd
Upload
563 views1 page

Fall Prevention Consent

This document is a fall prevention consent form from San Lazaro Hospital in Manila, Philippines. It informs the patient that they were made aware of the risks of falling while hospitalized. It notes that complications can still occur even with quality care. It also states that fall prevention is a shared responsibility of the patient/guardian and the hospital. The patient agrees to follow safety precautions and will not hold the hospital responsible for any issues resulting from a fall. The form requires signatures from the patient, guardian if applicable, and a witness.

Uploaded by

NicoleAbdon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
563 views1 page

Fall Prevention Consent

This document is a fall prevention consent form from San Lazaro Hospital in Manila, Philippines. It informs the patient that they were made aware of the risks of falling while hospitalized. It notes that complications can still occur even with quality care. It also states that fall prevention is a shared responsibility of the patient/guardian and the hospital. The patient agrees to follow safety precautions and will not hold the hospital responsible for any issues resulting from a fall. The form requires signatures from the patient, guardian if applicable, and a witness.

Uploaded by

NicoleAbdon
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOC, PDF, TXT or read online on Scribd
You are on page 1/ 1

Republic of the Philippines

Department of Health
SAN LAZARO HOSPITAL
Manila, Philippines

FALL PREVENTION CONSENT

Date Admitted: _______________ Hospital No.: ______________ Department: ______________


Name: _______________________________________________________________________
SURNAME FIRST NAME MIDDLE NAME
Age: ________ Sex: __________ Birthdate: _______________ Room/Bed No.: ______________

This is to certify that I, ____________________________ was informed and recognized the risk
(Patient’s/Guardian’s Name)
for fall. I understand that problems and complications may occur even when comprehensive
quality patient care, skills and judgment are provided. I acknowledged that fall prevention is a
shared responsibility between the patient/relative and the institution.

I conform to the instituted precautions and understand that San Lazaro Hospital and its Medical
Staffs will not be held responsible for any untoward implications of the fall.

______________________________ ___/___/___ _______


Patient’s Signature over Printed Name Date Time

In case the patient is minor (<18 years old or is physically disabled/incompetent

_________________________________________________________ ___/___/___ _______


Signature of Relative/Guardian over Printed Name - Relation to Patient Date Time

I have further explained the identified risk for fall to the patient/relative and answered all the
questions to the best of my knowledge. The patient/relative is well informed and acknowledged as
they consent this agreement.

________________________________ ___/___/___ _______


Signature of Witness over Printed Name Date Time

Sama-Sama, Tulong-Tulong… Go ISO…

You might also like