I, the undersigned, declare that I will abide by the Qatar Ministry of Public Health Circular No. 2/2021 which has been issued by Department of Healthcare Professions dated 21/04/2021 and is available on MOPH Website that all healthcare facilities (Public/Private/Semi-Governmental) must display 'Patients' Bill of Rights & Responsibilities' in three different Languages including Arabic and English languages as mandatory in a prominent, clear area for example waiting areas, receptions of all clinics etc.

I hereby, declare to acknowledge the availability of the Bill on MOPH Website in different languages as per MoPH issued circular and I have read the guidelines for implementation of patients' bill of rights and responsibilities in all healthcare facilities in the state of Qatar which is also available on Website in both languages' Arabic & English and full compliance with all mentioned in it.

The facility will take full responsibility in case of violation & non-compliance with all mentioned above.

Name: .................................................................................

QID: .....................................................................................

Attach copy of QID

Name of the Facility: .........................................................

Position in the Facility: .......................................................

Signature: .......................................................................

Facility stamp:

Date:.........................................................