Patricia P. Pelingo, M.D.
PEDIATRICIAN
HOSPITAL AFFILIATIONS:
Date:
Patient:
Address:
Age / Sex:
RX
+ Add medicine
− Remove last medicine
Notes:
Follow-up:
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Patricia P. Pelingo, M.D.
PRC License No.
86830
PTR No.:
Patricia P. Pelingo, M.D.
PEDIATRICIAN
HOSPITAL AFFILIATIONS:
MEDICAL CERTIFICATE
Date:
TO WHOM IT MAY CONCERN:
This is to certify that
,
years old,
, residing at
, has been seen and examined in this clinic on
with the following diagnosis:
RECOMMENDATION / RX
Advised to rest for
day(s)
Fit to return to work
Fit to work
Fit to travel
Cleared for school admission / school activities
For further work-up and referral
Details / referral:
Additional remarks:
Not for medico-legal purposes.
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Patricia P. Pelingo, M.D.
PRC License No.
86830
PTR No.:
Patricia P. Pelingo, M.D.
PEDIATRICIAN
HOSPITAL AFFILIATIONS:
LABORATORY REQUEST
Date:
Patient’s Name:
Age:
Sex:
Address / Contact No.:
PhilHealth PIN (if applicable):
REQUESTED LABORATORY TESTS
CBC
Urinalysis
Fecalysis
Fasting Blood Sugar
HbA1c
Lipid Profile
Creatinine
BUN
Uric Acid
SGPT / ALT
SGOT / AST
Electrolytes
Thyroid Profile
Pregnancy Test
Occult Blood
Other:
Additional tests / special instructions:
Clinical diagnosis / indication:
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Patricia P. Pelingo, M.D.
PRC License No.
86830
PTR No.:
Prescription (RX)
Medical Certificate
Lab Request
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