CONSENT FOR HOSPITAL CARE:

Permission is hereby given to the medical, nursing and laboratory staff of Lorma Medical Center to perform diagnostic procedures and administer medications and treatments as may be deemed necessary or advisable by the physician of this hospital for the above-named patient during this confinement. It is understood that such procedures may include blood transfusion, intravenous or infusions, administration of serums, antitoxin for treatments of prophylaxis, local or general anesthesia, spinal puncture, sternum puncture, x-rays, and laboratory tests.

My attending Doctor is:

Date:

PATIENT ACCOUNT RESPONSIBILITY FORM:

ROOM NO.

Air Conditioned

Private

Ward

ICU

Former Patient: Yes No

PhilHealth: Yes No

Company Account: Yes No

Lorma’s philosophy of Christian concern adheres to the policy of giving patients the best possible emergency lifesaving care without the need to make a deposit. However, during your stay with us we do expect periodic payments for services already rendered, and prior to discharge and all bills must be paid in full. Philhealth forms also must be submitted prior to bill processing, if not the account must be paid subject to future refund from Philhealth.

I further disclose that I was admitted within the last three (3) months with the following date/s:

Date/s of Confinement	Hospital	Case Rates/ Diagnosis

I hereby agree to the terms of the above contract service;

I may not be able to pay my hospital biills in full. I will request financial agreements for charity based from your existing policies and guidelines.

SURETY:

I/WE, EITHER or ANY OF US, hereinafter referred to as the surety, DO HEREBY BIND MYSELF/OURSELVES with the Patient-Debtor to make full payment of the obligation hereinabove set forth. In case of default by Patient-Debtor in the payment of the said obligations, the Surety agrees to pay Lorma Medical Center all outstanding obligations or the Patient-Debtor. The liability of the Surety shall be solidary, direct and immediate.

IF MINOR OR UNABLE TO SIGN:


Patient's Signature	Relative's Signature	Relative's Name in Print

Signature of Surety	Surety's Name in Print	Surety's Address