Pursuant to the provisions of the Data Privacy Act of 2012, I hereby give my free and voluntary consent
for Riverside Medical Center, Inc., (owner and operator of the Dr. Pablo O. Torre Memorial Hospital), its
staff, personnel, agents or authorized representatives for the collection, use, sharing and transmittal by any means and
processing of my personal information, medical information or privileged information as set out in my Riverside Medical Center, Inc.
Data forms, records, medical diagnosis, medical results and findings, and/or any other document or media provided by me or already
possessed by Riverside Medical Center, Inc., for purposes relevant to my consultation, diagnosis, treatment, tests or
for any other instances mandated by law.
I have read and fully understood the privacy statement of Riverside Medical Center, Inc.