Patients Experience Survey

Patients Experience Survey
I. DATA PRIVACY CONTENT
INFORMATION REGISTRATION & GENERAL CONSENT *
IMPORTANT: PLEASE READ CAREFULLY. YOU MAY REQUEST THE HOSPITAL STAFF TO EXPLAIN TO YOU, OR TO REFER YOU TO SOMEONE WHO CAN EXPLAIN TO YOU, YOUR RIGHTS TO YOUR PERSONAL INFORMATION. In the course of your treatment, Sacred Heart Hospital of Malolos, Inc. (the “Hospital”) will process Personal Information and Sensitive Personal relating to you and/or your spouse/parents/children/relatives/guardian/companion (“Contacts”), as applicable. Such processing of Personal Information may include its collection, recording, updating, modification, retrieval, use and retention. These Personal Information include information which may use for identification purposes and other personal circumstances such as your name, age, date of birth, address, nationality, gender, religious affiliation, contact information, educational background, medical information, medication, medical history and other information which are relevant for the purpose of your diagnosis and treatment in the Hospital. In signing this consent form, you are giving your consent to the following: 1) The processing of your Personal Information, as provided under applicable laws, regulations and the Hospital’s policies and guidelines, for its and its affiliates’ related entities and partners’ legitimate purpose/s including your testing, diagnosis, and treatment. 2) Making your Personal Information available to the Hospital, its affiliates, related entities, and partners (including its service providers as well as members of its medical staff and doctors) (Hospital related Entities), and to permit the Hospital Related Entities to make your personal data available to (a) third parties who provide products and services to the Hospital and the Related Hospital Entities for the same purpose described above; and (b) to other third parties (such as, but not limited to, the Department of Health, Philippine Health Insurance Corporation, your employer or your insurance provider), where required or permitted by law or contract, including regulatory authorities, government agencies, as well as parties with whom you voluntarily transact. 3) The processing of your Personal Information for medical training, research, and education, as well as to generate statistical data relevant to the Hospital’s operation in order to aid the Hospital’s management team, board of directors and shareholders to review and analyze data relating to the Hospital’s operations and financial performance. You also warrant that, before providing us with the Personal Information of your Contacts, you have obtained their consent to: (a) you collecting their Personal Information; (b) you sharing the same with the Hospital and the Hospital Related Entities and their third parties that the Hospital Related Entities are dealing with as provided in the immediately preceding paragraph; and (c) to the processing of their Personal Information by the Hospital, the Hospital related Entities and third parties as provided herein, and for the purposes stated herein. The Personal Information you provide will be retained by the Hospital for a period of 15 years (“Personal data retention Period”), or as long as necessary for the purpose of maintaining your medical records and to comply with applicable laws, rules and regulations on retention of data. Unless retention for longer period is required for reasonable cause, we will dispose of your Personal Information upon the lapse of the Personal Data Retention Period in accordance with applicable laws and regulations. You and your Contacts are entitled to certain rights in relation to the Personal Information that may be collected from you and your Contacts, including the right to access, correction, and to object to the processing of the same. A more detailed description of your rights under the Philippine Data Privacy Act of 2012, and its implementing rules and regulations may be downloaded at https://privacy.gov.ph/implementing-rules-and-regulations-of-republic-act-no-10173-known-as-the-data-privacy-act-of-2012/ You may consult the Hospital’s Data Protection Officer or the National Privacy Commission (contact details provided below) for any concerns regarding your Personal Data. Hospital’s Data Protection Officer Riavelle Love D. Santos (044) 794-4744; 794-7135 Diagnostic and Medical Arts Bldg., Sacred Heart Hospital of Malolos, Bulacan 3000 National Privacy Commission (0945) 153-4299 / (0939) 8715 3rd Floor, Core G, GSIS Headquarters Bldg. Financial Center, Pasay City, Metro Manila 1308
II. Tell us about yourself
Outpatient (hindi naconfine)Inpatient (naconfine)
Room No.*
Date of confinement*

MonthDayYear
Date
Date of Visit*

MonthDayYear
Date
Name*

First NameMiddle NameLast Name
YesNo
Name of Companion*

First NameMiddle NameLast Name
Phone Number*
Please enter a valid phone number.Format: (+63) 000-000-0000.
Address*

Street/Barangay

Street Address Line 2

CityState / Province

Postal / Zip Code
Email
example@example.com

Rows	Poor	Fair	Good	Very Good	Excellent
Courtesy and Respect of Staff
Clarity of Instruction
Quality of Care
Promptness

Rows	Poor	Fair	Good	Very Good	Excellent
Cleanliness
Comfort During Your Stay
Quality of Linen
Toilet and Bathroom (sink, faucet, toilet, flush)
Room Amenities (bed, cabinet, ref, etc.)

Rows	Poor	Fair	Good	Very Good	Excellent
On Time Delivery
Appropriate Food for the Diet of the patient
Courtesy and Respect of Staff
Taste of Meals
On Time Collection
Presentation of Meals

Rows	Poor	Fair	Good	Very Good	Excellent
Promptness
Courtesy and respect of staff
Clarify of Instruction
Timeless of Medication
Quality of Care

Rows	Poor	Fair	Good	Very Good	Excellent
Courtesy and respect of staff
Clarify of Instruction
Efficiency
Promptness

Patients Experience Survey

I. DATA PRIVACY CONTENT

II. Tell us about yourself

Ancillary and Other Department

Comment and Suggestion