International Travelers Medical Center

LG-01, Makati Palace Hotel

5011 P. Burgos cor. Caceres Sts. Brgy. Poblacion, Makati City
Contact. Nos. (+632) 259-9396;
Globe +63 905 408 5010; Sun/Smart +63 932 612 8777
Email Address: itmcmanila@gmail.com

Date of Prescription: June 30, 2021

Patient Information
Name: Vitan, Lina Perez
Nickname: Tita Lina
Birthdate: October 01, 1947
Home Address: #194 Bonga Menor, Bustos Bulacan

Rx:
Clonazepam 2 mg/tablet (Two Milligrams Only) - FOR ANXIETY
(Rivotril) # 30 (Thirty Pieces Only)
Sig: Please take one tablet, for anxiety, once a day, preferably during bed time

ORIGINAL COPY
DUPLICATE COPY
TRIPLICATE COPY

VERY IMPORTANT REMINDER/s:

This prescription is valid 60 days from date of issuance

NO REFILL

Prescriber Information:

Jumel Valecuatro Bornilla, M.D

PRC License No. 0103031
S2 License No. 001495RM19-041
S2 License Validity: July 02, 2022
Professional Tax Receipt No: 8530270

Clinic Name:International Travelers Medical Center

Address: Makati Palace Hotel, Unit 01, Lower Ground, 5011 P. Burgos Street, Corner Caceres Street,
Barangay Poblacion, Makati City
Contact Details:
Clinic’s Landline: +632 256 9396
Clinic’s Mobile Number/s: SUN/SMART +63 932 612 8777 and GLOBE +63 905 408 5010
Clinic’s Email address: itmcmanila@gmail.com

www.itmcmanila.com
 International Travelers Medical Center
LG-01, Makati Palace Hotel
5011 P. Burgos cor. Caceres Sts. Brgy. Poblacion, Makati City
Contact. Nos. (+632) 259-9396;
Globe +63 905 408 5010; Sun/Smart +63 932 612 8777
Email Address: itmcmanila@gmail.com

Date of Prescription: June 30, 2021

Patient Information
Name: Vitan, Lina Perez
Nickname: Tita Lina
Birthdate: October 01, 1947
Home Address: #194 Bonga Menor, Bustos Bulacan

Rx:
Clonazepam 2 mg/tablet (Two Milligrams Only) - FOR ANXIETY
(Rivotril) # 30 (Thirty Pieces Only)
Sig: Please take one tablet, for anxiety, once a day, preferably during bed time

ORIGINAL COPY
DUPLICATE COPY
TRIPLICATE COPY

VERY IMPORTANT REMINDER/s:

This prescription is valid 60 days from date of issuance

NO REFILL

Prescriber Information:

Jumel Valecuatro Bornilla, M.D

PRC License No. 0103031
S2 License No. 001495RM19-041
S2 License Validity: July 02, 2022
Professional Tax Receipt No: 8530270

Clinic Name:International Travelers Medical Center

Address: Makati Palace Hotel, Unit 01, Lower Ground, 5011 P. Burgos Street, Corner Caceres Street,
Barangay Poblacion, Makati City
Contact Details:
Clinic’s Landline: +632 256 9396
Clinic’s Mobile Number/s: SUN/SMART +63 932 612 8777 and GLOBE +63 905 408 5010
Clinic’s Email address: itmcmanila@gmail.com

www.itmcmanila.com
 International Travelers Medical Center
LG-01, Makati Palace Hotel
5011 P. Burgos cor. Caceres Sts. Brgy. Poblacion, Makati City
Contact. Nos. (+632) 259-9396;
Globe +63 905 408 5010; Sun/Smart +63 932 612 8777
Email Address: itmcmanila@gmail.com

Date of Prescription: June 30, 2021

Patient Information
Name: Vitan, Lina Perez
Nickname: Tita Lina
Birthdate: October 01, 1947
Home Address: #194 Bonga Menor, Bustos Bulacan

Rx:
Clonazepam 2 mg/tablet (Two Milligrams Only) - FOR ANXIETY
(Rivotril) # 30 (Thirty Pieces Only)
Sig: Please take one tablet, for anxiety, once a day, preferably during bed time

ORIGINAL COPY
DUPLICATE COPY
TRIPLICATE COPY

VERY IMPORTANT REMINDER/s:

This prescription is valid 60 days from date of issuance

NO REFILL

Prescriber Information:

Jumel Valecuatro Bornilla, M.D

PRC License No. 0103031
S2 License No. 001495RM19-041
S2 License Validity: July 02, 2022
Professional Tax Receipt No: 8530270

Clinic Name:International Travelers Medical Center

Address: Makati Palace Hotel, Unit 01, Lower Ground, 5011 P. Burgos Street, Corner Caceres Street,
Barangay Poblacion, Makati City
Contact Details:
Clinic’s Landline: +632 256 9396
Clinic’s Mobile Number/s: SUN/SMART +63 932 612 8777 and GLOBE +63 905 408 5010
Clinic’s Email address: itmcmanila@gmail.com

www.itmcmanila.com