Health Scheduling Form

Annual Physical Exam (APE)

GENERAL DETAILS
FIRST NAME MIDDLE NAME LAST NAME
JENNIFER NARSOLIS LAPUZ

DATE OF BIRTH MOBILE NUMBER* EMAIL ADDRESS

06-04-75 9464168830 jennarlapz_1517@yahoo.com
(MM-DD-YY)
LEVEL OF POSITION PREFERRED DATES OF HEALTH CHECK (Please provide at least 3 dates; MM/DD/YY)
Level 400-601 17 April 2023 Hi-Precision Diagnostics - Kawit Branch
     

Employee Disclaimer:

We, International SOS (Phils.), Inc. (“International SOS”), are contracted by your employer, cxLoyalty (“cxLoyalty”) to
assist you with the arrangement of your health check and related services with third party providers. By engaging
International SOS, you hereby authorize International SOS, to the extent permitted by applicable laws, to collect, process,
use, store, disclose, release, transfer your personal data and medical information to cxLoyalty for the purpose of
coordinating and facilitating the said service in that, amongst others, for obtaining authorization for coverage of expenses
and reporting of compliance to cxLoyalty. You further authorize the disclosure of your personal particulars and health
information to such third party providers for processing in relation to your health check.

Preferred Location (You may select more than 1 branch of preference)

HI-PRECISION MY HEALTH

CENTRAL METRO MANILA MANILA CITY MANILA

HP DIAGNOSTIC PLUS (FORT FESTIVAL MALL
BONIFACIO)  ☐ HP LACSON  ☐ ALABANG  ☐
HP DIAGNOSTIC PLUS ROBINSONS PLACE
ROCKWELL  ☐ T.M. KALAW BRANCH  ☐ ERMITA  ☐
SHANGRI-LA EDSA
HP PLUS AURA BRANCH  ☐ TAFT AVENUE  ☐ MANDALUYONG  ☐

HP PLUS AYALA BRANCH  ☐ QUEZON CITY SM NORTH EDSA  ☐

DEL MONTE, QUEZON CITY VENICE GRAND CANAL
HP PLUS MCKINLEY  ☐ BRANCH  ☐ MCKINLEY  ☐
EAST AVE., QUEZON CITY
HP PLUS ORTIGAS BRANCH  ☐ BRANCH  ☐
MAYBUNGA PASIG BRANCH  ☐ HP PLUS VERTIS NORTH  ☐
NS AMORANTO BRANCH  ☐ HPD COMMONWEALTH  ☐
PIONEER, PASIG  ☐ V LUNA BRANCH  ☐
OTHER LOCATIONS SOUTHERN METRO MANILA
HP DIAGNOSTIC PLUS
HP CAINTA  ☐ ALABANG  ☐
HP PLUS BF HOMES
HP VALENZUELA  ☐ BRANCH  ☐

HPD ANTIPOLO  ☐ LAS PINAS BRANCH  ☐

SUCAT BRANCH  ☐

Special Instructions:

1. Take note that you are unable to reply back to an email outside your organization.
2. You may coordinate your annual health check via email or phone call to International SOS by using your personal
 email or phone so the communication will not be restricted.
3. We request that you provide International SOS all information we need based on the scheduling form we shared.
4. By contacting International SOS, we expect that you agree with the “Employee Disclaimer” in this scheduling form.
5. We will share the health check inclusion and the preparation required for your health check once your schedule is
confirmed.
6. Kindly be advised that we’ll book the earliest possible available date of your preferred health check schedule to
any of your preferred branch of medical provider.
If not all procedure are available in your preferred branch, International SOS will recommend other clinic which can
accommodate all procedure in one day.
7. You may only reschedule for maximum of 3 times within your hire month for employees in Manila and within the
annual health check period for employees in Cebu.
8. Late notification of rescheduling or cancellation may result to cancellation fee from the medical provider. To avoid
cancellation charges, please contact International SOS 72 business hours before your scheduled health check.
Cut off period to notify cancellation is at 4PM.
9. You are encouraged to complete your annual health check on the same day of your scheduled appointment. If for
any reason there are incomplete medical exams, please go back to the medical provider to complete them within
10 days from the initial visit.
10. Scheduling forms are available at the clinic. You may fill up the form and submit it at the clinic as another option.

Should you have any question or concern in relation to your annual health check, you may email us at
CXLoyalty@internationalsos.com or call +632 8540 2730.