NOTRE DAME DE CHARTRES HOSPITAL

Department of Physical Medicine and Rehabilitation

PT SCHEDULE CARD

PATIENT’S NAME:______________________________________ CP # 0917-503-4233 TEL # 619-8531 TO 34 LOC 7104

Date Time PT Signature Px signature Remarks Date Time PT /Signature Px signature Remarks

NOTRE DAME DE CHARTRES HOSPITAL

Department of Physical Medicine and Rehabilitation

PT SCHEDULE CARD

PATIENT’S NAME:______________________________________ CP # 0917-503-4233 TEL # 619-8531 TO 34 LOC 7104

Date Time PT Signature Px signature Remarks Date Time PT /Signature Px signature Remarks
 GUIDELINES FOR PHYSICAL THERAPY TREATMENT

1. HMO Patients
1.1 Secure an approved LOA;
1.2 Obtain your Physical Therapy Schedule Card (PTSC);
1.3 Attach approved LOA to PTSC.
Note: No approved LOA, no treatment schedule or PTSC. All approved LOAs will be charged whether or not the patient comes for treatment.
2. Paying Patients
21. Present Official Receipt (OR) to the Rehab Receptionist;
2.2 Obtain PTSC.
Note: No OR, no treatment schedule or PTSC
3. Cancelled Treatment
3.1 Patients who cancel their scheduled treatment forfeit their right for treatment. It is non-refundable and non-transferrable; except: (1) in case of
force majeure or (2) cancellation is due to hospital’s/ PT staff initiative/Physician’s Order.
Note: Rescheduling shall be honored as soon as another approved LOA or OR is presented.
4. Late Arrival
4.1 All treatments will be disrupted if patients come in late. To avoid this, the Therapist reserves the right to cancel the treatment as soon as your
scheduled time of treatment is over.
4.2 Patients with remaining time of 30 minutes or more until the scheduled slot is over can still be accommodated at the therapist’s discretion except
for Winback and TRT treatment.

Reminders:
1. Patients may be accommodated for treatment on the same day the OR or an approved LOA is presented depending on the availability of the Therapist.
2. PTSC must be presented to the Therapist before every treatment session.
3. All treatments must be acknowledged both by the patient and the therapist by affixing their signature in the PTSC.
4. Lost PTSC will be charged Php 50.00

GUIDELINES FOR PHYSICAL THERAPY TREATMENT

1. HMO Patients
1.1 Secure an approved LOA;
1.2 Obtain your Physical Therapy Schedule Card (PTSC);
1.3 Attach approved LOA to PTSC.
Note: No approved LOA, no treatment schedule or PTSC. All approved LOAs will be charged whether or not the patient comes for treatment.
2. Paying Patients
21. Present Official Receipt (OR) to the Rehab Receptionist;
2.2 Obtain PTSC.
Note: No OR, no treatment schedule or PTSC
3. Cancelled Treatment
3.1 Patients who cancel their scheduled treatment forfeit their right for treatment. It is non-refundable and non-transferrable; except: (1) in case of
force majeure or (2) cancellation is due to hospital’s/ PT staff initiative/Physician’s Order.
Note: Rescheduling shall be honored as soon as another approved LOA or OR is presented.
4. Late Arrival
4.1 All treatments will be disrupted if patients come in late. To avoid this, the Therapist reserves the right to cancel the treatment as soon as your
scheduled time of treatment is over.
4.2 Patients with remaining time of 30 minutes or more until the scheduled slot is over can still be accommodated at the therapist’s discretion except
for Winback and TRT treatment.

Reminders:
1. Patients may be accommodated for treatment on the same day the OR or an approved LOA is presented depending on the availability of the Therapist.
2. PTSC must be presented to the Therapist before every treatment session.
3. All treatments must be acknowledged both by the patient and the therapist by affixing their signature in the PTSC.
4. Lost PTSC will be charged Php 50.00