Republic of the Philippines)

City of Manila……………) S.S.

AFFIDAVIT OF SELF-EMPLOYED PROFESSIONAL

I, BEATRIX BASA ONG, Filipino, of legal age, single and with address at No. 108
Montgomery Road 222 Montgomery Place, E. Rodriguez Sr., Ave., Quezon City, after being
duly sworn to in accordance with law, hereby depose and state:

That I am a practicing Dentist at Binondo Dental Care Clinic at Rm. 508 Allied Bank
Bldg., 410 Quintin Paredes St., Binondo, Manila;

That the following are the present service rates that are charged to my clients for the
dental care services rendered indication the manner of billings and the factors I consider in
determining the service fees:

A. RESTORATION: Light Cure – P850.00/service, Facing – P3,000.00/service, sealants

– P650.00, Temporary Filling – P450.00, Glass lonomer – P600.00, Build-up –
P3,500.
B. ORAL PROPHYLAXES – ranges from P600.00 – P800.00.

C. ROOT CANAL TREATMENT – P5,000.00/canal

D. EXTRACTION – Anterior – P700.00

Posterior P800.00
E. MOUTHGUARD – P5,000.00/arch
F. DENTURE – Complete Denture – ranges from P20,000.00 to P25,000.00
- Unilateral Denture – ranges from P10,000.00 to P15,000.00
- Bilateral Denture – ranges from P12,000 to P15,000.00
- Assemble Denture – P10,000.00
- Flexite (Unilateral – P12,000.00/arch
(Bilateral) – P16,500.00/arch
- Flexite + Framework – P22,000.00/arch

That the clients are billed as service rendered, collection of payment is then made after
the service is rendered, the Official Receipt is duly issued and the service income is recorded in
the cash receipts book duly registered with the Bureau of Internal Revenue;

That I am executing this affidavit to attest to the truth of the above statement and for
whatever legal intents and purposes it may serve.

IN WITNESS WHEREOF, I have hereunto set my hand this day of at Manila.

BEATRIX BASA ONG

Affiant

SUBSCRIBED AND SWORN to before me this 8th day of January, 2019. Affiant
exhibited to me her PRC ID No. 35560, as competent proof of identity.

Doc. No.
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Book No.
Series of 2019