DR. GERALD B. BURGOS GEN.

DENTISTRY AND ORTHODONTICS

Cor. Legaspi and Arellano Streets, Roxas City Tel. No. 6-212-724

CLINIC HOURS: 9:00 AM 12:00 NN * 2:00-5:00 PM Monday to Saturday

July 7, 2011

DENTAL CERTIFICATE
TO WHOM IT MAY CONCERN: This is to certify that TERESITA D. CAMPBELL, 53 years old of BOLO, ROXAS CITY, PHILIPPINES has undergone Dental Treatment at my office on the following date stated below: Tooth Surface 1. #35 Occluso-Mesial 2. #45 Occluso-Mesial 3. #48 Occlusal Cavity 4. Description of Service Class 2 Amalgam Filling Class 2 Amalgam Filling Class 1 Amalgam Filling Upper and Lower Impression Taking (Bilateral Partial Denture) 5. Upper and Lower Partial Denture May 16, 2011 Delivered (Flexite) Total Fee: Php 33,000.00 Php 30,000.00 Date of Service May 10, 2011 May 10, 2011 May 10, 2011 May 10, 2011 Fee Php 1000.00 Php 1000.00 Php 1000.00

GERALD B. BURGOS, DMD Lic. No. 14822 PTR No. 0033565