You are on page 1of 1

Annex D

Note: This is not valid if used more than 24hrs after injury.

PHILIPPINE GENERAL HOSPITAL


Department of Emergency Medicine
the National University Hospital
University of the Philippines Manila
PHIC-Accredited Health Provider
ISO 9001: 2008 Certified

PGH Form No. P-50006

4454576
Case No: __________________ 5 July 2019
Date: _____________
Pauline A. Luna
Name: ___________________________________________ 35/F
Age/Gender: _______
MI mauling 1) soft tissue swelling
Impression: ____________________________________________________________
2) shoulder, 3) right chest area,
______________________________________________________
4) bruises in the neck
________________________________________________________________
________________________________________________________________
Duration of Treatment: ___________________________________________________
PIA GUANIO
UP-PGH Surgery
Lic. No. 0136931
__________________________________
Signature over Printed Name

Note: This is not valid if used more than 24hrs after injury.

You might also like