REPUBLIC OF THE PHILIPPINES )

Laoag City )

AFFIDAVIT

I, Dr. Roxy Galasinao, of legal age, single and resident of Brgy. ______,
Laoag City after having been duly sworn to in accordance with law do hereby depose
and state that:

1. I am a medical practitioner specializing in Urology for 26 years now, at

Black Nazarene Hospital, INC. located at #29 Bonoan, St, San Nicolas,
Ilocos Norte

2. I have graduated and earned my Medicine degree at the University of the

Philippines – Manila in April 1993;

3. I have first hand knowledge of the facts and opinion set forth herein;

4. Andres Bukid is my patient since I started practice, and he has been

diagnosed as impotent since he was _______ years old by his previous
doctor.

5. Last May 10, 2019 at around 2pm, Mr. Bukid went to my clinic and
requested for a potency test

6. A Medical Certificate is issued by me as to the condition of the patient,

(herein Respondent) attached as Annex “A”.

7. I examined said patient through physical examinations and his clinical

history. Other tests like laboratory test (UA,CBC,etc.) and potency test
were likewise examined.

8. After thorough examination, I found out that the patient Mr. Bukid was
IMPOTENT;
9. I hereby attest to the truth based on my knowledge and findings and to
testify in court based on the foregoing facts.

IN WITNESS WHEREOF, I hereunto affix my signature this ___ day of ____

at Laoag City, Ilocos Norte.

DR. ROXY GALASINAO

Affiant SSS ID No. 123456

SUBSCRIBED AND SWORN to before me this ______ day of September, 2019 at

Laoag City, as competent proof of their identity, the affiants exhibited their respective
government issued ID as indicated below their names. Affiants signed the
abovementioned document in my presence.

Witness my hand and seal.

 Atty. DANIELLE JAN S. QUIDILLA
Notary Public
Until December 31, 2019
IBP No. 766890, 1-30-2019; Laoag City
PTR No. 7865146, 1-30-2019; Laoag City
MCLE Compliance No. II-0001094
ROOM 109, HSGE Building, Rizal St.
Laoag City

Doc. No. 003

Page No. 001
Book No. I
Series of 2019