Health Declaration & Release of Liability


Section 1

In accordance with RA 11332, sections 9 and 10, otherwise known as Mandatory Reporting of Notifiable Diseases and Health Events of Public Health Concern, you are required tp provide correct information. Incorrect information or non-disclosure may be grounds for a criminal case against you, resulting in a fine of Php 20,000 to Php 50,000 and/or imprisonment of up to six months.

Section 2

Adventist Medical Center Bacolod is a HEALTHCARE FACILITY; community transmission of COVID-19 constantly coming to the hospital for treatment entails the risk of contracting COVID-19 from commuting or contact with high-risk frontline staff.


Having read the aforementioned, I hereby agree as follows:

– By my own free will, I choose to enter the premises of BAMC and avail of its services. I also waive any right to hold Adventist Medical Center-Bacolod liable for any charges/expenses incurred for RT-PCR and/or hospital admission should I/or my patient contract COVID-19 from co-patient, watchers, doctors, and staff visitors.

– I declare that the information I have given above is true, correct and complete. I understand that non-disclosure or failure to provide correct information is punishable under RA 11332, and I am subject to a fine or imprisonment or both as stipulated by RA 11332.

I recognize that by completing this form I am contributing to the effort of BAMC in providing me/my patient a safe environment and allowing her to provide the right services due to me/my patient.