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    Consent Waiver

    Uploaded by

    lendiodexter92
    This consent form outlines the services provided and limitations of Damulog Birthing Clinic in accordance with Philippine Department of Health guidelines. The clinic provides prenatal care, normal vaginal deliveries, postnatal care, and basic newborn care, but is not equipped to handle C-sections, complicated procedures, intensive neonatal care, high-risk pregnancies, or medical complications. Patients who choose to deliver at the clinic understand they may need to transfer for emergencies or high-risk situations.

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    © All Rights Reserved
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    Consent Waiver

    Uploaded by

    lendiodexter92
    36 views2 pages
    This consent form outlines the services provided and limitations of Damulog Birthing Clinic in accordance with Philippine Department of Health guidelines. The clinic provides prenatal care, normal vaginal deliveries, postnatal care, and basic newborn care, but is not equipped to handle C-sections, complicated procedures, intensive neonatal care, high-risk pregnancies, or medical complications. Patients who choose to deliver at the clinic understand they may need to transfer for emergencies or high-risk situations.

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    Consent/Waiver Sample

    Original Title

    ConsentWaiver

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    This consent form outlines the services provided and limitations of Damulog Birthing Clinic in accordance with Philippine Department of Health guidelines. The clinic provides prenatal care, normal vaginal deliveries, postnatal care, and basic newborn care, but is not equipped to handle C-sections, complicated procedures, intensive neonatal care, high-risk pregnancies, or medical complications. Patients who choose to deliver at the clinic understand they may need to transfer for emergencies or high-risk situations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    36 views2 pages

    Consent Waiver

    Uploaded by

    lendiodexter92
    This consent form outlines the services provided and limitations of Damulog Birthing Clinic in accordance with Philippine Department of Health guidelines. The clinic provides prenatal care, normal vaginal deliveries, postnatal care, and basic newborn care, but is not equipped to handle C-sections, complicated procedures, intensive neonatal care, high-risk pregnancies, or medical complications. Patients who choose to deliver at the clinic understand they may need to transfer for emergencies or high-risk situations.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Download as docx, pdf, or txt
    of 2

    Consent/Waiver Form

    Patient Name: ___________________________


    Date: _______________
    Medical Record Number: _______________

    This consent/waiver form is intended to inform you about the scope and limitations of
    services provided at Damulog Birthing Clinic, in accordance with the guidelines set forth by the
    Department of Health (DOH) of the Philippines. Please read this form carefully and ask any
    questions you may have before signing it.

    Scope of Services
    Damulog Birthing Clinic is a primary birthing facility that provides the following services:
     Prenatal care
     Normal spontaneous vaginal delivery (NSVD)
     Postnatal care
     Basic newborn care

    Limitations
    As a primary birthing clinic, we are guided by DOH guidelines. Hence, we are not
    equipped to handle:
     Cesarean sections
     Complicated labor and delivery
     Neonatal Intensive Care Unit (NICU) services
     High-Risk Pregnancies, which include but are not limited to:
    o Maternal age below 18 or above 35
    o Gravidity of 5 or more
    o Parity of 4 or more
     Any medical or obstetric complications

    Department of Health Guidelines


    We adhere to the DOH guidelines, which include but are not limited to:
     Sterile and safe birthing environment
     Availability of skilled birth attendants
     Referral systems for high-risk or emergency cases

    Risks and Alternatives


    By choosing to deliver at Damulog Birthing Clinic, you understand and acknowledge the
    scope and limitations, and do agree to be transferred to a higher-level facility in case of
    complications or if you fall under the high-risk categories mentioned above.
    CONSENT

    I, ___________________________, have read and understood the scope and limitations of


    services at Damulog Birthing Clinic as set forth by this facility in accordance with the DOH
    guidelines. I acknowledge that I fall under the category of HIGH-RISK Pregnancy as defined
    above. That said, I hereby voluntarily choose to receive childbirth services at this facility.

    _____________________________
    Signature Above Printed Name
    Date and Time:

    Witness/es Signature Above Printed Name:

    1. _____________________________ Date and Time:

    2. _____________________________ Date and Time:

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