I nsul ar Heal th Car e I nc.

2/F Insular Health Care Building

167 Dela Rosa corner Legaspi Streets
Legaspi Village, Makati City 1229
Metro Manila, Philippines
Tel. No. (632) 813-0131
Toll Free 1800-10-8177857 Fax: (632) 893-
5953
A Subsidiary of The Insular Lif e Assurance Company, Ltd. http://www.insularhealthcare.com.ph

REFERRAL SLIP
Date : 09/16/2021 Approval Code : 0921249511
To : Dr. Alvin Peniaf iel From : 0921249511
Hosp. : Green City Medical Center-Pampanga Pref. Hosp. : Age/Sex : 63 / F
Patient : Carlos, Teresa D. ID Number : 00364601 Expiration Date : 07/31/2021

Reason For Referral / Chief Complaints Findings / Diagnosis

Management Given / Procedures Performed Remarks

CONSULT LOA Validity Extended up to 09/20/21 PPE and other
miscellaneous items NOT covered

Carlos, Teresa D.
Patient's Name and Signature Date Examined Specialist's Name and Signature

Please fill up forms completely and legibly to facilitate payment. Kindly submit within 60 days from date of availment. Thank you.