GX INTERNATIONAL INC.

CHOLESTEROL STRIPS CLAIM FORM

Dispensing MD

DM NAME : ___________________________________
DISTRICT : ___________________________________
DATE:

No. NAME OF DOCTOR CLINIC ADDRESS BAROMETER SAATIN SI # SI DATE MACHINE CHOLE. STRIPS
DRUGSTORE
1 DR. NELSON ABELARDO MANILA DOCTORS HOSPITAL MED EXPRESS 6+2 2019-001 JAN. 7, 2019 1 BC CHOLE. MACHINE 10
2 DR. DONNY MAGNO AUF HOSPITAL, PAMPANGA AUF PHAR. 9+3 2019-002 JAN. 7, 2019 1 BC CHOLE. MACHINE 10
3 DR. NOE BABILONIA PHC, QUEZON CITY PHC PHAR. 12+4 2019-003 JAN. 7, 2019 1 BC CHOLE. MACHINE 20

DM SIGNATURE BC SIGNATURE PM SIGNATURE

 GX INTERNATIONAL INC.

HYPERTENSION DIABETES FREE CLINIC - PATIENT LIST

SSE NAME : ___________________________________ DATE : _______________________________________
DISTRICT : ___________________________________ VENUE : _______________________________________
DMs NAME : ___________________________________ MD : _______________________________________

no. NAME OF PATIENT AGE Signature BP TC FBS Product Prescribed # of Tablets Prescribed # of Tablets Purchased # of Samples Given

1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
16
17
18
19
20
21
22
23
24
25
26
27
28
29
30
 GX INTERNATIONAL INC.
HYPERTENSION DIABETES FREE CLINIC VALIDATION FORM

SSE KRISANTO PARINO MONTH Jan-19 FOR BC VALIDATION

Date of
Activity
Venue / Drugstore MD Name SSE S. I. # S.I Date Product Quantity Amount
Betacard 6.25mg ₱0.00
Betacard 25mg ₱0.00
GX Amlodipine 5mg x 30's 60 ₱13,902.00
MARCH 16,2019 ALICIA ISABELA,HOLYLAND PHARMACY LAYLANI ALUBIA KRISANTO PARINO GX Amlodipine 10mg x 30's 60 ₱9,241.20
Neosartan 50mg x 30's ₱0.00
Neosartan 100mg x 30's ₱0.00
Neosartan Plus x 30's ₱0.00
Total ₱23,143.20
Arya 1 mg x 30"s ₱0.00
Patient Gathering Checklist (Choose one group only) Arya 2 mg x 30"s ₱0.00
Barangay Coordination ANTONIO ABUAN Arya 3 mg x 30"s ₱0.00
(Name of Barangay Official) Neoform 500mg x 100's ₱0.00
Senior Citizen Neoform 500mg x 100's ₱0.00
(Name of Senior Citizen Group) Total ₱0.00
Civic Organization TOTAL 46,286.40

(Name of Organization ex. Rotary Club, Sorority, Knight of Columbus, Jaycees, Kiwanis, TODA, Couples for Christ etc. )
Industrial Outlets SAATIN 10mg x 100's ₱0.00
(Coke, Pepsi, Del Monte, San Miguel, Convergys, PLDT, Phil Airlines) SAATIN 20mg x 100's 3 ₱3,348.21
Others SAATIN 40mg x 100's 3 ₱4,955.37
(School Alumni, Parents / Teachers Association,Parish Church ) Green Stevia x 100's ₱0.00
Truetea Iced Tea x 4's ₱0.00
Brief Descriptio TO UNLOAD GX PRODUCTS AND RE ENROLL AGAIN IN THE HPN DIABETIC FREE CLINIC AND HAVE A PATIENT LOYALTY TO THE DRUGSTORE.
Please mark x for corresponding strips availment

X Entitled for 10 Cholesterol Strips

Entitled for 20 Cholesterol Strips
Entitled for 30 Sugar Strips
Submitted by Entitled for 15 Sugar Strips

District Manager
* Note for Chain DS see mechanics

Validated by

Approved by
Branch Coordinator / Date
Product Manager / Date
 GX INTERNATIONAL, INC.
ACKNOWLEDGMENT RECEIPT
RECEIVED THE AMOUNT OF __________________________________________________________
___________________________ (_________________) AS HONORARIUM FEE FOR CONDUCTING A FREE CLINIC/MEDICAL MISSION/ETC. (PLS.
SPECIFY)___________________________________________ AT
(VENUE/DRUGSTORE)_____________________________________________________________ ON (DATE)___________________________.

RECEIVED BY: GIVEN BY:

SIGNATURE OF MD:_____________________________________ ______________________________

SIGNATURE OVER PRINTED NAME
FULL NAME OF MD:_____________________________________ SSE/DM/DATE

ADDRESS:_____________________________________________

TIN NO. ______________________________________________

CONTACT NO.:_________________________________________
 GX INTERNATIONAL
HPN & DIABETES FREE CLINIC - POST ACTIVITY RECORD
DATE OF ACTIVITY:
NAME OF DRUGSTORE:
NAME OF MD:
NAME OF SSE:
DISTRICT:

GX INTERNATIONAL
HPN & DIABETES FREE CLINIC - POST ACTIVITY RECORD
DATE OF ACTIVITY:
NAME OF DRUGSTORE:
NAME OF MD:
NAME OF SSE:
DISTRICT: