SurgeOnCall Registration Form

Reservation Form

Kindly fill-up with the PATIENT'S information.
Name of Patient*

First NameLast Name
Age*
Address*
Home Visit/other procedures are limited to residents within NCR and Cavite (during Saturdays) only
Mobile No.*
Format: 0000 000-0000.
Service To Avail*
Preferred Date and Time (Subject to Availibility)*
Data Privacy Content

By submitting this form, I am fully aware that SurgeOnCall is under duty bound and obligated under the Data Privacy Act of 2012 to protect all my personal and sensitive information that it collects, processes and retains upon submission of this form to process my order. I understand that my personal information cannot be disclosed without my consent. Likewise I am fully aware that SurgeOnCall may share such information to other healthcare professionals in cases of referrals. In this regard, I hereby allow SurgeOnCall to collect, process, use and share my personal data in the pursuit of its legitimate interests as a healthcare/surgical service provider. Finally, should I commit any misconduct or should there be a complaint filed against me, by reason of violation of their terms and policies, I hereby authorize and give my full consent in favor of SurgeOnCall to share my information to the authorities or the public.

Consent Form
Kindly read first.
The law of the state requires that consent is obtained prior to beginning of any surgical procedure. In this regard, I hereby give authorization to SurgeOnCall and its associates to conduct or perform circumcision unto my son.

I understand that circumcision is a procedure in which the foreskin (fold of skin that covers the end of the penis is surgically cut or removed). The nature of a circumcision, and the benefits to be reasonably expected have been explained to me and my son.

I understand that unforeseeable circumstances may arise during the procedure that may result in the need of undergoing another procedure other than what has been set forth. In such case, I authorize SurgeOnCall doctor and/or his/her assoiates to perform such necessary procedure should it be needed as it is deemed best, in their professional judgment.

In relation to the procedure specified in this Informed Consent, I have been given an opportunity to ask questions and by which it was responded to properly and to my satisfaction. I assume the possible risks involved in the procedure as well as the possibility of which the desired results may not be guaranteed.

The fees for the service have been explained to me and by which I allow and authorize the undersigned doctor, including his/her associates, render any treatments necessary or recommended for my condition, including administration or prescription of anesthetics and/or medications.

Further, I understand that the medications administered or prescribed for this procedure may cause drowsiness. I am aware that I am prohibited from consuming alcohol or other drugs during and before the taking of medication
Name (Parent/Guardian)

First NameLast Name
Date

MonthDayYear
Date
Take photos but do not include face/identityI hereby grant SurgeOnCall and its associates the right to take photograph of me/ my patient during the procedureI hereby grant permission and give my full consent to SurgeOnCall and its associates for the use of photograph(s) or electronic media images obtained during my procedureI agree that its use for online publication may be made without compensation or additional consideration of me

Should be Empty:

Reservation Form

Consent Form