Date:

________________________
________________________
DPOTMH

Dear _____________________________:

In view of our Case Study on the concept of (concept name), may we ask for approval to render
volunteer duty in your are on _________________ at ________________________.

Please find the patient’s name for your perusal:

Patient’s name:________________________________
Chief Complaint:_______________________________
Initial diagnosis:________________________________
Room no./Ward no.:____________________________
Attending Physician:____________________________
We are hoping for your kind consideration.

Respectfully yours,

Jacob Candiasan ______________ Le Dionaldo ______________

Antonio Chua III ______________ Ashley Tipsay ______________

Ma. Thea Claparol ______________ Ernesto Torre ______________

Joselou Cordova _______________ Alex Serviano ______________

NOTED: NOTED:

(name and signature of concept lecturer) (name of the headnurse)

Concept Lecturer headnurse
station #, DPOTMH
Mrs. Liza T. Chan
Level Chairman
Date:

________________________
________________________
DPOTMH

Dear Dr. __________________________:

We, the BSN3 students currently enrolled in NCM 103 will be presenting a case on the concept of as part
of our course requirement.

In this view, we are asking for your approval to make your patient as our subject in the Case
Presentation.

Please find the patient’s name for your perusal:

Patient’s name: ______________________________

Chief Complaint: ______________________________
Initial diagnosis: ______________________________
Room no./Ward no.:____________________________
Attending Physician:____________________________

Rest assured that whatever patient’s information we gathered will be strictly confidential.
Thank you very much.
Respectfully yours,

Jacob Candiasan ______________ Le Dionaldo ______________

Antonio Chua III ______________ Ashley Tipsay ______________

Ma. Thea Claparol ______________ Ernesto Torre ______________

Joselou Cordova _______________ Alex Serviano ______________

NOTED: