City of Taguig City of Taguig

City Health Office City Health Office

PALINGON HEALTH CENTER PALINGON HEALTH CENTER

NAME: __________________________ DATE: __________ NAME: __________________________ DATE: __________

ADDRESS: ________________________ AGE/SEX: _______ ADDRESS: ________________________ AGE/SEX: _______

℞ ℞

_________________, MD _________________, MD
LICENSE NO: _________ LICENSE NO: _________
PTR NO: _____________ PTR NO: _____________

City of Taguig City of Taguig

City Health Office City Health Office
PALINGON HEALTH CENTER PALINGON HEALTH CENTER

NAME: __________________________ DATE: __________ NAME: __________________________ DATE: __________

ADDRESS: ________________________ AGE/SEX: _______ ADDRESS: ________________________ AGE/SEX: _______

℞ ℞

_________________, MD _________________, MD
LICENSE NO: _________ LICENSE NO: _________
PTR NO: _____________ PTR NO: _____________
 City of Taguig City of Taguig
City Health Office City Health Office
PALINGON HEALTH CENTER PALINGON HEALTH CENTER

NAME: __________________________ DATE: __________ NAME: __________________________ DATE: __________

ADDRESS: ________________________ AGE/SEX: _______ ADDRESS: ________________________ AGE/SEX: _______

LABORATORY REQUEST LABORATORY REQUEST

 CBC with Platelet Count  CBC with Platelet Count

 Urinalysis  Urinalysis
 Fecalysis  Fecalysis
 Dengue Duo  Dengue Duo
 Blood Chemistry: ______________________________________  Blood Chemistry: _______________________________________
_____________________________________________________ _______________________________________________________

 RT-PCR  RT-PCR
 X-RAY: __________________  X-RAY: __________________
 Ultrasound: _______________  Ultrasound: _______________
 OTHERS: _________________________________________  OTHERS: _________________________________________
_________________, MD _________________, MD
LICENSE NO: _________ LICENSE NO: _________

City of Taguig City of Taguig

City Health Office City Health Office
PALINGON HEALTH CENTER PALINGON HEALTH CENTER

NAME: __________________________ DATE: __________ NAME: __________________________ DATE: __________

ADDRESS: ________________________ AGE/SEX: _______ ADDRESS: ________________________ AGE/SEX: _______

LABORATORY REQUEST LABORATORY REQUEST

 CBC with Platelet Count  CBC with Platelet Count

 Urinalysis  Urinalysis
 Fecalysis  Fecalysis
 Dengue Duo  Dengue Duo
 Blood Chemistry: ______________________________________  Blood Chemistry: _______________________________________
_____________________________________________________ _______________________________________________________

 RT-PCR  RT-PCR
 X-RAY: __________________  X-RAY: __________________
 Ultrasound: _______________  Ultrasound: _______________
 OTHERS: _________________________________________  OTHERS: _________________________________________
_________________, MD _________________, MD
LICENSE NO: _________ LICENSE NO: _________