_________________

(Date)

Dr. GERARDO AQUINO

Medical Center Chief II
Vicente Sotto Memorial Medical Center
Cebu City

Dear Dr. Aquino,

Greetings!

This is to respectfully refer herein patient, _________________________________________

with residence address at ______________________________________________________,
an OPD patient/Admitted at ____________________ for assistance under the Medical
Assistance Program of Sen. Pia S. Cayetano for the patient’s specific need for
___________________________________________________________________________
in the amount of Php______________________.

Thank you.

Patient’s Information:

Full Name: __________________________________________________________________

Date of Birth: __________________ Gender: _____________ Civil Status: _______________
Complete Address: ___________________________________________________________
Contact Number: ______________________ Signature: _____________________________

Very respectfully yours,

DR. NERITO “REY” A. MARTINEZ, Ph.D.