REPUBLIC OF THE PHILIPPINES )

CITY OF ____________ ) SS.

AFFIDAVIT

I, ______________, Filipino, of legal age, and with residence at

______________, after being duly sworn, hereby depose and say that:

1. I am a Physician by profession practicing internal medicine;

2. As a physician, my rate for clinic fees is as follows:

Basic consultation/check-up -P 400.00

3. The manner of billing is as follows:

Patients pay at the clinic immediately after the consultation or check-up;

and

4. I am executing this affidavit to attest to the truth of the foregoing narration

of facts and for whatever legal purpose this affidavit may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this

______________________, at ________________, Philippines.

_________________
Affiant

SUBSCRIBED AND SWORN to before me this __________________, at Davao

City, Philippines, affiant exhibiting to me his/her Professional Regulations Commission
ID No. ____________ valid until ____________ as her competent evidence of identity.

Doc. No. ____;

Page No. ____;
Book No. ____;
Series of 2014.