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Details

LOA No. Mobile No. Gender Patient name Birth date Age Address (not in SMS) Date examined Chief complaint / Diagnosis Remarks / Recommendation Rx (medicines, lab requests) Save these three as a template named

Share which forms? Medical Certificate Rx

BF Mactan Strip UNIT 2-L M.L. Quezon Ave., Pajo, Lapu-Lapu City
Telephone no.: GLOBE (032) 412-1094 & (032) 406-1493

MEDICAL CERTIFICATE

To whom it may concern,

This is to certify that Mr.

Years of age, residing at

was examined and treated at Life & Health Laboratory on

with chief complaints / DIAGNOSIS

REMARKS/RECOMMENDATION:

Physician’s Sig:Philip March Alquizar, MDLicense No.:112870PTR No.:1592096S2 No.:

BF Mactan Strip, Unit 2-LM.L. Quezon National Highway, Pajo, Lapu-Lapu City
Tel. No.: (032) 412-1094 & (032) 406-1493
Cel. No.: 0917-805-1684 & 0922-501-1330

NAME: DATE:

ADDRESS: AGE:

Physician’s Sig: PHILIP MARCH R. ALQUIZAR, MD
License No.: 112870
PTR No.: 1592096
S2 No.:

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