11/9/22, 3:54 PM Poseidon®

 
Pre-Employment Medical Examination Referral  

SF Code: 22-02578

Seafarer: JOHN LOUIS TOLENTINO ADMANA    Position: DECK CADET 

Permanent Address: BOLITOC, STA CRUZ ZAMBALES Philippines 
Email:      Mobile #:   
Date of Birth: 09 Nov 00, Th | 22y    Place of Birth: ZAMBALES 
Gender: Male    Passport # | Expiry:  | 
Marital Status: Single    Seaman's Book | Expiry:   |  
      SRN: 0011090025 

Vessel:  CHILEAN BULKER   Vessel Type:   Bulk Carrier Referral Date: 11 Nov 22, Fr
 
Principal:  Synergy Marine Pte. Ltd. Vessel Flag:   Denmark Valid Until: 11 Nov 22, Fr

Instruction to Seafarer
1. You are schedule for medical examination 11 Nov 22, Fr  (clinic hours are from 7:00 am - 4:00 pm Monday - Friday / 8:00 am -
     
on 12:00 pm Saturday)
  2. You will be examined at   SUPERCARE MANILA / 573 Patria Building, Maria Orosa Ermita, Manila, Philippines  
3. Please bring  This Referral
 Passport & Seaman's Book copy
 Valid government-issued ID (Driver’s License, SSS ID, Postal ID)
 Stool sample in sterilized bottle
     
 Corrective eye glasses or contact lens; if using contact lens, avoid wearing them 24
hours prior your examination
 Any previous medical record if and when available such as:
Chest x-ray film done within the last 6 months
Ophthalmologist color test or clearance (if Ishihara defective/color blind)
Operation record/medical certificate (if with history of operation/surgery)
  4. Please observe fasting   No food or fluid intake within 10 hours prior to blood extraction  
  5. Wear Comfortable Clothing      
 
  (please answer truthfully, in accordance with Sec. 20 of the POEA Standard Terms and Conditions)  
 
Reason for last repatriation:
 End of Contract  Accident(Attach Medical Report)
     
 Illness(Attach Medical Report)
 
I agree to undergo pre-employment medical examination at the clinic stated above. I am aware that my medical results will be disclosed
   
and reviewed by the clinic's medical staff and will then be forwarded to my agency.
  JOHN LOUIS TOLENTINO ADMANA
        Name of Seafarer  
 

Instruction to Clinic
  1. Please conduct the following examinations   Flag: Denmark *  LIKE UK P&I PACKAGE  
  2. Payment charged to    
 Agency/Company  Examinee

Authorization
This record is not valid without the original signature and if beyond the referral validity  
  date indicated above.   Ann Sachiko S. Kato  
Authorized Signatory

Synergy Group Operations, Inc.

4th Floor SM Cyber Makati One Building, 373 Sen. Gil J. Puyat Avenue, Bel-Air Village, Makati City Philippines 1209
Tel: +63 2 8538 3400 - 3499
Inquiry: mail@synergygroup.ph

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