I nsul ar Heal th Car e I nc.

No. 167 Dela Rosa corner Legaspi Streets

Legaspi Village, Makati City 1229
Metro Manila, Philippines
Tel. No. (02) 813-01-31, 8404 (of f ice hours)
(02) 817-78-57, 8404 (af ter of f ice hours)
A Subsidiary of The Insular Lif e Assurance Company, Ltd. http://www.insularhealthcare.com.ph

ENDORSEMENT FOR ANNUAL PHYSICAL EXAMINATION

Hosp./ Clinic Name Carmona Hospital And Medical Center, Inc. Control No. 072116791
Address Gov Driv e Cor Purificacion Sts. Macaria Business Center Date 07/28/2021
Mabuhay, Carmona, Cav ite
Telephone No Valid Until 08/28/2021

046 419 8110, 049 559 8180

Company Sw ifserv Customer Serv ices Co.

Member ID Member Name Age/Gender Birthdate

00304396 BASA, GINA S. 47 / F 10/09/1973

00304398 CABUHAT, DENNIS R. 48 / M 06/16/1973
00304401 DE JESUS, JANET I. 38 / F 10/07/1982
00304394 LUNA, KENDRICH KARL B. 28 / M 09/13/1992
00304393 LUNA, KYLE KEVIN B. 26 / M 03/16/1995
00304402 SUERTE, RAINE JILLIAN D. 15 / F 05/13/2006

APE PACKAGE: OTHERS:

Physical Examination ECG f or 35 y/o & above
Chest X-ray Pap Smear f or 35 y/o & above
CBC
Routine Urinalysis
Stool Exam

Remarks Please call the Clinic/Facility to conf irm schedule Medical results f or pick-up "PPE cost/MedCert, if
any, is not covered"

Note to Cl i ni c/ Hospi tal : Please see attach copy of this endorsement to your billing statement. Only those members endorsed and those
medical test mentioned above shall be valid for payment. Kindly forward to Insular Health Care, Inc. within 60
days from date of availment.

Prepared by:

JEREMIAH OLLYR N. VERGONIO