LOA-22-1375

DATE
LETTER OF AUTHORIZATION 14-June-2022
NAME OF PATIENT
Roger Sarmiento Ventura
NAME OF FACILITY
St. Luke's Medical Center -Quezon City
CONSULTATION/EXAMINATION/PROCEDURE REQUEST
Follow-up Consultation - 4:00 PM
SPECIALIST/ATTENDING PHYSICIAN DIRECT REFERRAL
Arnel Chua
OTHER PATIENT INFORMATION:

*We request that no billing documents (Statement of Account/Charge Invoice) shall be issued by the Billing
Department - Cashier to the patient.

We guarantee further that payment will be settled from our end.

Kindly note that this LOA is valid only on the day of test/procedure. Please coordinate with any of our personnel
at 0917-634-4202/0917-160-5377 / 0920-538-2633/0919-436-3539 if you have any concerns.
FOR CONSULTATION, MAY WE REQUEST FOR A MEDICAL REPORT AFTER. Email to the following:

Medical Director : marilarmd@shiptoshore.com.ph

Post Medical Doctor 1 : postmd1@shiptoshore.com.ph
Post Medical Doctor 2 : postmd2@shiptoshore.com.ph

Prepared by: Rene Rose G. Dariguez

Noted by: MARILAR F. DE GUZMAN, MD

Medical Director

IMPORTANT ( Instruction for Patient Admission): Medical expense of the patient will be charged to our account. Meals or any food
ordered will be at the patient’s cost.

 3/F, Maria Cornelia Bldg. 222 Sen. Gil Puyat Ave., Makati City, Philippines
Contact Nos.: 0917-634-4202/0917-160-5377 / 0920-538-2633/0919-436-3539

SSMA Form No. PRM-76-02(5/6/22)