DocuSign Envelope ID: 1A32754F-5B9E-4E90-8060-DFE963CF1230

NEW CANAAN INSURANCE AGENCY

PRE-EMPLOYMENT PHYSICAL EXAMINATION SCHEDULE FORM

Date Issued:________________________________ Valid Until:____________________

Name:________________________________________ Age: ___ Sex: [ ] Male [ ] Female

Pre-EMPLOYMENT PROCEDURES:
Complete Physical Examination
Complete Blood Count (CBC)
Urinalysis
Fecalysis
Chest x-ray
Drug Test (Shabu & Marijuana)

Important Reminders:
• This form may be presented at Aventus Clinic (please refer below for the address) together with any 2 valid government issued IDs.
• Urine specimen containers will be provided at the clinic. Kindly collect a mid-stream urine sample during the day of examination and immediately submit to the
laboratory. (Female can submit a specimen at least 7 days after the last day of menstruation).
• The patient should collect a pea sized stool specimen in the morning before proceeding to the clinic and must be submitted to the Laboratory within 2 hours after
collection.
• A separate urine container will be provided for the Drug Test. It is advisable to have a full bladder for the required level of urine (60ml).
• For the Drug test, patient is required to present 2 valid ID (company ID, driver's license, Fire arm license, GSIS ID, Integrated Bar of the Phils., NBI Clearance, Overseas
Filipino Worker's ID, Overseas Filipino Worker's Adm. ID, Passport, Police clearance, PRC license, School ID, Seaman's book, Senior Citizen's ID, Solo Parent ID, SSS ID, TIN,
Voter's ID) prior to any availment.
• A patient with prescription eyeglasses and/or contact lenses should bring the same during the examination for Visual Acuity.
• No fees will be collected from the patient. PPE cost are charged thru Intellicare.
• All hard copy of PPE results should be forwarded to New Canaan Insurance Agency, Inc. located at 3F, BMG Centre, Paseo de Magallanes, 1232 Makati City, Philippines

• Contact Person: Alfonso Lotilla, Contact Number: (02) 8531245 to 47, (0917) 881-2106
• Repeat examination/clearances (i.e repeat urinalysis, pulmo clearance, cardio clearance) will be shouldered by the patient.
ALFONSO LOTILLA
_______________________________ _________________________________________________________
Applicant’s signature Name and Signature of Authorized Representative
CLINIC COPY

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HR COPY
Confirmation of Pre-employment Examination:

(Once the above examination is complete, detach this portion and submit it to HR/Recruitment)

PPE TESTS COMPLETED: YES

WITH PENDING TEST/S: TO COME BACK ON:

Candidate’s printed name: Date: Time:

Candidate’s signature: Signature of Nurse-on-duty:
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CLINIC ADDRESS:

AVENTUS MAKATI CLINIC

6th Floor Filomena Bldg. 104 Amorsolo Street, Legaspi
Village Makati
Tel: #261-2886; 261-2888, 519-6787, 817-1464, 817-2715
Clinic Hours for PPE: Mon-Sat. 8am-3pm (no lunch break)