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  • Surigao Doctors' Hospital Central Supply Form

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    Gerald Talledo
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    The document contains a central supply form for Surigao Doctors' Hospital in Surigao City, Philippines. The form includes fields to record a patient's name, date of admission, date of birth, age, sex, attending physician, nurse on duty, items supplied and their quantities, descriptions, charges and total charge. The form is repeated four times.

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    Original Title

    CENTRAL SUPPLY

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    The document contains a central supply form for Surigao Doctors' Hospital in Surigao City, Philippines. The form includes fields to record a patient's name, date of admission, date of birth, age, sex, attending physician, nurse on duty, items supplied and their quantities, descriptions, charges and total charge. The form is repeated four times.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    30 views1 page

    Surigao Doctors' Hospital Central Supply Form

    Uploaded by

    Gerald Talledo
    The document contains a central supply form for Surigao Doctors' Hospital in Surigao City, Philippines. The form includes fields to record a patient's name, date of admission, date of birth, age, sex, attending physician, nurse on duty, items supplied and their quantities, descriptions, charges and total charge. The form is repeated four times.

    Copyright:

    © All Rights Reserved
    Download as DOCX, PDF, TXT or read online from Scribd
    Flag for inappropriate content
    of 1

    SURIGAO DOCTORS’ HOSPITAL, INC. SURIGAO DOCTORS’ HOSPITAL, INC.

    Sitio Kinabutan, Brgy. Rizal, Surigao City Sitio Kinabutan, Brgy. Rizal, Surigao City
    “A Hospital with a Heart” “A Hospital with a Heart”

    CENTRAL SUPPLY CENTRAL SUPPLY


    Case No.__________ Case No.__________
    Room No.__________ Room No.__________

    Charge to the Account Of_____________________________________________ Charge to the Account Of_____________________________________________


    (Family Name/Given Name/Middle Name) (Family Name/Given Name/Middle Name)
    Date of Admission:___/___/20___ Time:____ am/pm OPD[ ] Date of Admission:___/___/20___ Time:____ am/pm OPD[ ]
    Date of Birth: ____/___/____ Age____ Sex:______ Date of Birth: ____/___/____ Age____ Sex:______

    QTY DESCRIPTION CHARGE QTY DESCRIPTION CHARGE


    . .

    TOTAL TOTAL

    Attending Physician : Dr. ____________________________________ Attending Physician : Dr. ____________________________________


    Nurse-on-duty: __________________________________________ Nurse-on-duty: __________________________________________

    SURIGAO DOCTORS’ HOSPITAL, INC. SURIGAO DOCTORS’ HOSPITAL, INC.


    Sitio Kinabutan, Brgy. Rizal, Surigao City Sitio Kinabutan, Brgy. Rizal, Surigao City
    “A Hospital with a Heart” “A Hospital with a Heart”
    CENTRAL SUPPLY CENTRAL SUPPLY
    Case No.__________ Case No.__________
    Room No.__________ Room No.__________

    Charge to the Account Of_____________________________________________ Charge to the Account Of_____________________________________________


    (Family Name/Given Name/Middle Name) (Family Name/Given Name/Middle Name)
    Date of Admission:___/___/20___ Time:____ am/pm OPD[ ] Date of Admission:___/___/20___ Time:____ am/pm OPD[ ]
    Date of Birth: ____/___/____ Age____ Sex:______ Date of Birth: ____/___/____ Age____ Sex:______

    QTY DESCRIPTION CHARGE QTY DESCRIPTION CHARGE


    . .

    TOTAL TOTAL

    Attending Physician : Dr. ____________________________________ Attending Physician : Dr. ____________________________________


    Nurse-on-duty: __________________________________________ Nurse-on-duty: __________________________________________

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