Thanks to visit codestin.com
Credit goes to www.scribd.com

Scribd
Upload
259 views2 pages

Dosdh - Cif Watcher Waiver Form: (Age) (Relationship To Patient) (Name of Patient) (Name of Watcher)

This document is a waiver form from the Datu Odin Sinsuat District Hospital in the Philippines allowing a family member to act as a watcher for a COVID-19 patient. The form acknowledges the risks to the watcher and states they will follow all quarantine/isolation protocols. It is signed by the watcher and a witness.

Uploaded by

Princess
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
259 views2 pages

Dosdh - Cif Watcher Waiver Form: (Age) (Relationship To Patient) (Name of Patient) (Name of Watcher)

This document is a waiver form from the Datu Odin Sinsuat District Hospital in the Philippines allowing a family member to act as a watcher for a COVID-19 patient. The form acknowledges the risks to the watcher and states they will follow all quarantine/isolation protocols. It is signed by the watcher and a witness.

Uploaded by

Princess
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as DOCX, PDF, TXT or read online on Scribd
You are on page 1/ 2

Republic of the Philippines

Bangsamoro Autonomous Region in Muslim


Ministry of Health
Datu Odin Sinsuat District Hospital
Dalican, Datu Odin Sinsuat, Maguindanao

DOSDH – CIF WATCHER WAIVER FORM

Date: ________________

I, ___________________________________, ________ years old, hereby request to be the


(Name of Watcher) (Age)
watcher of patient Ms. /Mr. ______________________________ who is my
(Name of Patient) (Relationship to Patient)
________________. The patient is a __________________ case for Covid-19 and is admitted
(Covid-19 Case Classification)
for quarantine / isolation purposes in Datu Odin Sinsuat District Hospital – Covid-19

Isolation Facility.

I have been thoroughly informed of the risks and consequences of this decision and

will not hold the staff nor the management responsible / liable for all my undertakings

while I am in the facility. Rest assured that I will be strictly observing all the stated

quarantine / isolation protocol set forth by the facility and will cooperate to the

treatment plan of my patient.

The content of this form was explained to me in a language / dialect I understand and

its effect shall only cover the time of my admission to the date of my discharge from

the facility

WATCHER

(Signature over printed name)

WITNESS
(Signature over printed name)

You might also like