CONDITIONS OF SERVICE, INFORMED CONSENT, AND DATA PRIVACY NOTICE

for Laboratory Procedures and Diagnostic Services of D.I.P. Medical and Laboratory, Inc.

In consideration of the laboratory and diagnostic services to be provided by D.I.P. Medical and Laboratory, Inc. (“DIP”), I, the undersigned patient/client, parent, or duly authorized representative, freely and voluntarily state and agree as follows:

1. Consent to Laboratory and Diagnostic Services

I authorize DIP and its duly qualified physicians, medical technologists, radiologic technologists, nurses, phlebotomists, and other authorized healthcare personnel to perform the laboratory tests, specimen collection procedures, diagnostic examinations, and related services that have been requested by my attending physician, required by the requesting company or institution when applicable, or voluntarily requested by me, as may be appropriate to my case.

I understand that the nature, purpose, and general process of the requested procedure/s have been explained to me in a language and manner I can understand, and that I have been given the opportunity to ask questions before the service is performed.  

2. Information Provided to Me

I understand that laboratory and diagnostic procedures may involve specimen collection, imaging, and other routine or ancillary procedures. I acknowledge that I have been informed, to the extent applicable, of the following:

• the purpose of the requested test or procedure;

• the usual steps involved;

• reasonable and commonly known discomforts or risks, if any;

• important preparation requirements, if any;

• the possible need for repeat collection or repeat testing in cases such as inadequate specimen volume, contamination, hemolysis, labeling issues, machine error, quality control failure, or other valid technical reasons; and

• the need for additional or separate consent when required by law or by the nature of the procedure.  

3. Limits of Laboratory and Diagnostic Results

I understand that:

• laboratory and diagnostic results are part of clinical evaluation and should be interpreted together with my symptoms, history, physical examination, and other medical findings;

• no laboratory or diagnostic service can guarantee a particular medical outcome, diagnosis, or treatment result; and

• some results may be preliminary, require confirmation, correlation, repeat testing, or referral to another provider or facility.
  These limitations are consistent with the general principle of informed consent, which requires explanation of the nature of the procedure and relevant risks and uncertainties.  

4. My Responsibilities as Patient/Client

I agree to:

• provide complete, truthful, and accurate personal, clinical, and billing information relevant to the requested service;

• disclose, when relevant, medications taken, pregnancy status, allergies, recent procedures, or other conditions that may affect testing or interpretation;

• follow preparation instructions, specimen collection instructions, and safety protocols given by DIP personnel; and

• present valid identification or authorization documents when required.

I understand that inaccurate, incomplete, or withheld information may affect the quality, interpretation, release, or use of my results.  

5. Consent for Minors and Patients Unable to Give Consent

If the patient is a minor or is unable to provide valid consent, this form shall be signed by the parent, legal guardian, or duly authorized representative. The signer represents that he or she is legally authorized to act on behalf of the patient. Philippine patient-rights guidance recognizes consent through parents, guardians, or authorized representatives when the patient cannot validly consent.  

6. Emergency or Urgent Situations

In emergency or urgent circumstances where delay may place the patient at risk and obtaining prior written consent is not feasible, necessary action may be taken in accordance with applicable law and accepted medical practice. Philippine patient-rights guidance recognizes emergency exceptions to prior written informed consent.  

7. Privacy, Confidentiality, and Processing of Personal Data

I understand that DIP will collect and process my personal data and sensitive personal information, including health information, only for legitimate healthcare-related purposes such as patient identification, registration, test performance, result generation, quality assurance, billing, collection, reporting required by law, coordination with my physician or authorized payor, recordkeeping, and other purposes reasonably connected with my care and the operation of the laboratory.

I understand that my health information is protected under the Data Privacy Act of 2012 and related rules, and that DIP is required to implement appropriate safeguards for its protection. Health information is treated as sensitive personal information under Philippine privacy guidance.  

8. Release and Disclosure of Results

I understand and agree that my results may be released only to:

• me, upon proper identification;

• my parent, legal guardian, or duly authorized representative, when allowed by law and upon proper documentation;

• my attending physician or referring healthcare provider, when necessary for my care;

• the company, agency, institution, or payor that validly requested and paid for the service, only to the extent authorized by law, contract, and my consent or other lawful basis; and

• government authorities when reporting is required by law or lawful order.

Except as allowed or required by law, DIP shall not disclose my medical or laboratory information to unauthorized persons. Patients have a right to privacy and confidentiality, and disclosure of health information must have a lawful basis under the Data Privacy Act.  

9. Electronic Communication and Release of Results

Where applicable, I may choose to receive results through approved electronic means such as email, patient portal, or other secure digital channels designated by DIP. I understand that while DIP will apply reasonable safeguards, electronic transmission may carry residual privacy or security risks beyond DIP’s direct control. If I designate an email address, mobile number, or representative for release, I confirm that the information I provide is accurate and authorized for such use. Consent for processing and privacy notices must be validly obtained and managed under NPC guidance.  

10. Corporate, Employer, and Pre-Employment Accounts

If the service is requested under a company, agency, school, HMO, or other institutional account, I understand that DIP may process and release only the information reasonably necessary for the authorized purpose and in accordance with applicable law, valid consent, and data-sharing rules. For pre-employment, annual physical exams, or similar institutional programs, result release should be aligned with privacy law and the scope of the requesting party’s lawful authority.  

11. Separate Consents for Specially Regulated Tests

I understand that certain services may require a separate specific consent form or counseling under applicable law, policy, or professional standards. 

12. Refusal, Deferral, or Withdrawal

I understand that I may refuse a non-emergency procedure or withdraw my consent before the procedure is performed, subject to the consequences of such refusal being explained to me. However, I understand that refusal may result in non-performance of the requested service, incomplete evaluation, delay, inability to release certain reports, or other limitations in my care or transaction. Philippine patient-rights guidance recognizes the patient’s right to informed consent and to refuse non-emergency procedures.  

13. Billing and Financial Responsibility

I understand that applicable professional fees, laboratory charges, package rates, and other lawful charges for services requested and rendered shall be for my account or for the account of the requesting company, agency, institution, or payor, as applicable under the arrangement declared at registration. I agree to settle charges not covered by a package, company account, or other approved arrangement.

14. Confirmation

I confirm that:

• I have read this document or it has been read and explained to me in a language I understand;

• I was given the opportunity to ask questions and my questions were answered reasonably;

• I understand the nature and general purpose of the requested services, my privacy rights, and the limits on result release;

• the information I provided is true and complete to the best of my knowledge; and

• I voluntarily give my informed consent to the requested laboratory and diagnostic services.