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MANUEL S. ENVERGA UNIVERSITY FOUNDATION CANDELARIA INC.

Candelaria, Quezon
Name of Hospital / Home / Lying-in-clinic, Municipality/ City/ Province
ACTUAL DELIVERY in Magsaysay Memorial District Hospital, Lopez, Quezon

Printed Name with Signature of Student: Ezekiel R. Lopez


Prepared by:LOPEZ, EZEKIEL DELOS REYES

Date Performed Patient's Name DR Nurse on Duty Supervised by


and Case Number Procedure Performed (Names Only) Clinical Instructor
Time Started (not applicable for Birthing/ Lying in Clinics/ Homes) Name and Signature

Maricel P. Panganiban Normal Spontaneous Glady Erandio


March 1,2010 Joan Grace C. Piguerra
80605 Delivery PRC
2:30PM PRC no.
no. 0355717
0255717
May 28, 2009 Genalyn A. Valenzuela Normal Spontaneous
Glady Erandio Joan Grace C. Piguerra
11:34AM 75732 Delivery PRC
PRC no.
no. 0355717
0255717

Noted By: Rosario Natividad C. Bautista RN, MAN Approved by: Gaspar Hector C. Tapire, RN, MSN
Clinical Coordinator Dean

PRC ID No. 0184950 Valid Until October20,2012 PRC ID No. 0214894 Valid Until November4,2011
Date Signed Time Date Signed Time
PNA No. 009710 Valid Until October31,2010 PNA No. 051961 Valid Until October31,2010
ADPCN No. 0847 Valid Until ###
Concurred by LOIDA GUIA RN
Chief Nurse

PRC ID No. 082950 Valid Until November21,2011


Date Signed Time
PNA No. 6100 Valid Until life member