Republic of the Philippines

Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer

PURCHASE REQUEST
MUNICIPALITY OF VICTORIA
AGENCY/PROCURING ENTITY

DEPARTMENT: HEALTH PR No. Date: _______

SECTION: ________ SAI No. Date: _______

Item Unit Description QTY Unit Cost Total

no. Cost
Rabies Post Exposure Prophylaxis (PEP) Card 2
1 ream
1 ream Rabies Patient Record 2
1 ream Prescription 4
1 ream Patient Swab Information 1
1 ream Medical Certifcate (short) 2
1 ream Medical Certificate (small) 4
1 ream Urinalysis 3
1 ream Hematology 3
1 ream Family Planning (FP) Form 1 2
1 ream Fecalysis 3
1 ream Form 2a. NTP Laboratory Request and result 1
Form
1 ream Form 4. TB Treatment/IPT Card 1
1 ream Form 5. TB Identification Card 1
1 ream Form 7. NTP Referral Form 1
1 ream Referral Slip 1
1 ream Selection Criteria – Free X-Ray Service 1
1 ream Linelist of Specimen Reffered for Covid-19 1
Testing
1 ream Case Investigation Form (Covid-19) Version 9 1
1 ream PMRF 1
1 ream Authorization 1
1 ream Certificate of classification of at-risk individuals 1
and actual charges for SARS-CoV-2 test
1 ream UTM’s (Sansure) 1
1 ream Laguna Molecular Laboratory Request Form 1
for Sars-Cov-2 Detection by RT-PCR
1 ream Dengue RDT Laboratory Request Form 1
1 ream Partograph 1
1 ream Admitting Sheet 1
1 ream Kapahintulutan 1
1 ream Antenatal Record 1
1 ream Delivery Standing Order 1
1 ream Clinical Abstract 1
 Republic of the Philippines
Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer

1 ream Postpartum Record 1

1 ream Postpartum Standing Order 1
1 ream Apgar Score 1
1 ream Newborn Standing Order 1
1 ream Patient’s Health Education Sheet 1
1 ream Medication and Treatment Sheet 1
1 ream Doctor’s Progress Notes 1
1 ream Nurse’s Progress Notes 1
1 ream Midwife’s Progress Notes 1
1 ream New Born Service 1

Requested by:

Maria Kathleen Grace Concepcion R. Young, MD

Municipal Health Officer
Victoria, Laguna
 Republic of the Philippines
Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer

MUNICIPALITY OF VICTORIA
AGENCY/PROCURING ENTITY

DEPARTMENT: HEALTH PR No. Date: _______

SECTION: ________ SAI No. Date: _______

Item Unit Description QTY Unit Cost Total

no. Cost
1 ream Bond Paper (Legal 8½ X 13 70gsm 500 sheets) 20
1 ream Bond Paper (Legal 8.5 X 11 70gsm 500 sheets) 10
1 Pc Puncher Big heavy Duty 4
1 Pc Standar large Stapler 4
1 Pc L&C Refill Ink (Black) 5
1 Pc L&C Refill Ink (Magenta) 5
1 Pc L&C Refill Ink (Yellow) 5
1 Pc L&C Refill Ink (Oyan) 5

Requested by:

Maria Kathleen Grace Concepcion R. Young, MD

Municipal Health Officer
Victoria, Laguna
 Republic of the Philippines
Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer

Date: ________________

PATIENT SWAB INFORMATION

 Republic of the Philippines
Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer
 Republic of the Philippines
Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer

PATIENT’S RECORD
Name: Age: Birthdate:
Address: H/F: Date:

Vital Signs: Chief Complaint:

Temp:
BP:
Weight:
 Republic of the Philippines
Province of Laguna
Municipal Government of VICTORIA
Peregrina Rebong-Dator Memorial Health Center
(Rural Health Unit)
Office of the Municipal Health Officer

Philhealth No.: