Republic of the Philippines )

City of Butuan )
x--------------/

AFFIDAVIT OF ____________

I____________, Filipino, of legal age and a resident of __________, after

having been sworn to in accordance with law, do hereby depose and say
the following, that:

1. I am a registered professional nurse with Professional Regulations

Commission (PRC) since _______;

2. I am a nurse-employee of JSAButuan Orthopedic Institute which is a

clinic owned by Dr. Jerome Anthony S. Asuncion and is located
inside the hospital building of Butuan Doctor’s Hospital;

3. I worked with JSAButuan Orthopedic Institute as a nurse from _____

until____;

4. It was known to me ever since I started working at the clinic of Dr.

Jerome Anthony S. Asuncion that I am an employee of JSAButuan
Orthopedic Institute and not an employee of Butuan Doctor’s
Hospital;

5. As an employee of Dr. Jerome Anthony S. Asuncion, I know for a fact

that his clinic is named, identified and is known to be as JSAButuan
Orthopedic Institute and not as Advanced Wound Care Center, nor
any other name, calling or distinction;

6. It was Dr. Jerome Anthony S. Asuncion who personally hired me as

an employee of JSAButuan Orthopedic Institute;

7. It was Dr. Jerome Anthony S. Asuncion who personally directed,

controlled and supervised my work as a nurse at JSAButuan
Orthopedic Institute;

8. I receive my salaries and other benefits directly from Dr. Jerome

Anthony S. Asuncion for the work I performed at JSAButuan
Orthopedic Institute and not from Butuan Doctor’s Hospital;
 9. I conduct initial assessment and patient interview with respect to the
clients of JSAButuan Orthopedic Institute who are scheduled for
debridement surgical procedures;

10.I perform the vital signs taking and monitoring of the patients of
JSAButuan Orthopedic Institute before and after they underwent
debridement surgical procedures;

11.I prepare the operating/surgical materials and equipment necessary

for the conduct of debridement surgical operations inside JSAButuan
Orthopedic Institute;

12.As a nurse of JSAButuan Orthopedic Institute, I know for a fact that

Dr. Jerome Anthony S. Asuncion and Dr. Jess Avila conduct the
debdriment surgical procedures at JSAButuan Orthopedic Insititute;

13.I assist either Dr. Jerome Anthony Asuncion or Dr. Jess Avila in the
conduct of debridement surgical procedures as a surgical nurse or
circulating nurse inside JSAButuan Orthopedic Institute;

14.I perform the dressing of the wounds of the patients which

underwent debridement surgical procedure at JSAButuan
Orthopedic Institute;

15. I personally cause the recording and charting of the patient’s

information to the patient’s chart who underwent debridement
surgical procedures inside JSAButuan Orthopedic Institute;

16. I execute this affidavit freely, voluntarily and out of my free will, and
willful understanding of the meaning and import hereof, the contents
of this affidavit having been explained to me and that I fully know
and understand.

FURTHER, THE AFFIANT SAYETH NAUGHT.

IN WITNESS WHEREOF, I have hereunto set my hand this 18th day

of September, 2020 at Butuan City, Philippines.
 _________________________
Affiant
ID Presented/No._________
Expiry Date:______________

SUBSCRIBED AND SWORN to before me, this 18th day of

September, at Butuan City, Philippines, the affiant appearing before me
with his/her competent evidence of identity as above indicated. The affiant
is known to me or otherwise identified bvy competent evidence of identity
and he/she signed this document which is consisting of three (3) pages
including this page in my presence and swore that he/she understood the
contents thereof and that the same is his/her voluntary act and deed.

Doc. No.:_____;
Page No.:_____;
Book No.:_____;
Series of 2020.