1:mu1:zu DATA PRIVACY

LD Hl·PIUCIIION tp><•l'lt'Cl<ion AovAHCEO Hi-Precision Diagnostics respects and puts utmost priority on the confidentiality of your personal information.
.... 11. , • • • • 'l11c., Oaaonos\.lC$NJI LAB NO • Please read our Privacy Policy to understand how we protect and use your personal information in acconlance
PATIENT REGISIRATION SLIP PIO with Data Privacy Act of 2012, its Implementing Rules and Regulations, olller Issuances ol the National Privacy
Commission and other relevanl laws of the Philippines. You may access our PrlYacy Policy at our branches and
lhrough our website al hi-precision.com,ph.
PATIENT INFORMATION As a private client, 1understand lhat I mu.~t personally claim or access my resutts online.
LAST NAME FIRST NAME MIDDLE NAME As a corl)Orate client, I understand thal I must abide by the instructions given ID me by my employer I company /
HMO / insurance agent / broker regarding release of results. When required, I also give my consent and allow HPD
to post onilne and/or forward all the results of my medical examination including, but not limited lo laboratory and
BIRTHDATE (MM-DlHYYY) I AGE SEX AT BIRTH ancillary examinations, lo my employer I company/ HMO/ Insurance agent I broker.'
Male Female CONDITIONS OF SERVICE AND CONSENT FOR LABORATORY PROCEDURES/ DIAGNOSTIC EXAMINATIONS
, In consideration of services provided by HI-Precision Diagnostics ("HPDft), the Patient or tile legal guanflan
ADDRESS acting on bellalf of the Patient agrees and consents to the following:
1, Consent to Routine Medical Treatment/Services
Patient consents to the rendering Laboratory Procedures/Diagnostic Examinations as considered necessary and
appropriate by the attending physician or other practitioner. Patient authorizes 1he attending or other practitioner,
CONTACT NO/S. the medical staff of HPD and HPD to provide Laboratory Procedures/Diagnostic Examinations ordered or requested
by attending or other practitioner and those acting in his or her place. Patient fully ooderstands and accepts Ille
PHYSICIAN'S NAME (or indicate NIA if none} prices quoted for all the services which will be availed.
2. Explanation of Risk and Treatment Alternatives
Patient acknowledges that the practice ot medicine is not an exact science and lhat NO GUARANTEES OR
TEST REOUEST/S ASSURANCES HAVE BEEN MADE TO THE PATIENT concerning the outcome llld/or result o1 any Laboratory
Procedures/Diagnostic Examinations. Wrille routinely performed without incident, there. may be material risks
associated with each of these Laboratory Procedures/Diagnostic Examinations.
BULSU APE Branch: _______________________ By signing this form: Patient consents lo Healthcare Professionals performing Laboratory Procedures!Dlagnostic
Examin;itions as they may deem rea~onably necessary or desirable in .the exercise of their professional judgment,
including those Laoora1ory Procedures/Diagnostic Examinations that may be untoreseen or not knOwn to Ile
needed at the time this consent Is obtained: and Patient acknowledges that Patient has been Informed In general
lenns of lhe nature and purpose of Ille Laboralory Procedul9Sllliagnostic Examinations; the matertal risks of !he
Last meal time: __________________________ Laboratory Procedures/Diagnostic Examlnallons ancl practical alternatives to the Medical Treatment/Sel"fi~
If Patient has any questions or concerns regarcling these lalloratory ProcedUres/Oiagnostic Examinations, Patient
will ask Patill[ll'S attending provider to provide Patient wilh acldlllonal Information. Patient also understands that
Last menstrual period (if female): _____________ Patient's anendirig or olher provider may ask Patient to sign adclilional lnfonned consent documents concerning
these or other Laboratory Procedures/Diagnostic Examinations.
Patient acknowledges that a copy or an electronic version of this document may lie used·in place· of and Is as
Medications: _____________________________ valid as the original.
Patient understands that the Heallhcare Professionals participating In the Patient's care will rely on Patient's
documented medical history, as well as other lntonnation obtained from Patient, Patillllt's famlty or others
having knowledge about Patient, In determining whether to perfonn or recommend the Procedures; therefore,
Patient agrees to provide accurate and complete lntormaUon about Patient's medical history and conditions.
Patient confirms that Patient has read and understood and accepted the terms of this document and the
undersigned Is the PaUent, the Patient's legal representative or is duly authorized by the Patient as the
Patient's general agent to execute the above and accept Its tenns.

REMARKS:
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Patient or Legal Guardian's* Signature over Printed Name Date
•Note: ff signing as legal guardian for minor or incapacltatrld patifJnt, p1,as9 Ind/cats the
relationship to patier,t: _ _ _ _ _ _ _ _ _ _ _ __

FORM CREATED: June I. 2023