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    Patient Waiver Form: IN WITNESS WHEREOF, I Have Hereunto Affixed My Signature This - Day

    Uploaded by

    RexylPacayCainar
    The patient waiver form outlines an agreement between a patient and a medical provider regarding prenatal care and childbirth. It states that the patient received counseling and a checkup regarding her pregnancy. She agrees to give birth at a specified clinic. The patient also agrees to assume all risks and responsibilities if she does not follow the medical advice, and will not hold the provider liable for any issues arising from her own negligent or intentional acts regarding her pregnancy. She signs to acknowledge understanding and consent to the waiver.

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    © All Rights Reserved
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    Patient Waiver Form: IN WITNESS WHEREOF, I Have Hereunto Affixed My Signature This - Day

    Uploaded by

    RexylPacayCainar
    9K views1 page
    The patient waiver form outlines an agreement between a patient and a medical provider regarding prenatal care and childbirth. It states that the patient received counseling and a checkup regarding her pregnancy. She agrees to give birth at a specified clinic. The patient also agrees to assume all risks and responsibilities if she does not follow the medical advice, and will not hold the provider liable for any issues arising from her own negligent or intentional acts regarding her pregnancy. She signs to acknowledge understanding and consent to the waiver.

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    PATIENT WAIVER FORM.docx

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    The patient waiver form outlines an agreement between a patient and a medical provider regarding prenatal care and childbirth. It states that the patient received counseling and a checkup regarding her pregnancy. She agrees to give birth at a specified clinic. The patient also agrees to assume all risks and responsibilities if she does not follow the medical advice, and will not hold the provider liable for any issues arising from her own negligent or intentional acts regarding her pregnancy. She signs to acknowledge understanding and consent to the waiver.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    9K views1 page

    Patient Waiver Form: IN WITNESS WHEREOF, I Have Hereunto Affixed My Signature This - Day

    Uploaded by

    RexylPacayCainar
    The patient waiver form outlines an agreement between a patient and a medical provider regarding prenatal care and childbirth. It states that the patient received counseling and a checkup regarding her pregnancy. She agrees to give birth at a specified clinic. The patient also agrees to assume all risks and responsibilities if she does not follow the medical advice, and will not hold the provider liable for any issues arising from her own negligent or intentional acts regarding her pregnancy. She signs to acknowledge understanding and consent to the waiver.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 1

    PATIENT WAIVER FORM

    I, ______________________, of legal age, single/married and a resident of


    _______________________________________, do hereby agree and undertake the
    following, to wit:

    1. That I have been counselled, advised and conducted pre-natal check-up


    by _____________________ regarding my pregnancy on
    ______________________________.

    2. That I was further advised that I will give birth at the Hospital and/or Rural
    Health Unit of Ambaguio Birthing Clinic.

    3. That in case I will not follow the advised of ________________________, I shall


    assume any and all risks and shall take full responsibility for myself and my
    actions and shall further hold free and harmless
    _______________________________ and its officers, agents, and employees
    against all losses, damages, or liabilities resulting from claims, suits, and
    actions for injuries to persons (including death) to the extent caused by or
    arising out of any negligent, wanton or intentional act or omission on my
    part regarding my pregnancy.

    4. That I have read and understood the foregoing and acknowledge my


    consent to this Waiver by signing hereof.

    IN WITNESS WHEREOF, I have hereunto affixed my signature this_______ day


    of ____________at ____________________________________, Nueva Vizcaya.

    __________________________
    PATIENT’S SIGNATURE

    Witness/es:
    1. ______________________________
    2. ______________________________

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