* Cleft Consent *

Bago tayo magsimula, pumapayag ba kayo na ang mga impormasyon, documents and
pictures ng pasyente ay maging bahagi sa patient database ng MDF & Smile Train?
Confidential ang mga data ninyo at i share lang namin sila sa mga authorized na mga
tao kagaya ng mga partner doctors, hospital staff, other foundations, Smile Train &
donors.

Paki-reply ang sagot: "Oo, sumasang-ayon ako" or "Hindi ako sumasang-ayon"

* Cleft Patient Details *

Ang pasyente ay magiging bahagi ng patient database ng Mabuhay Deseret Foundation.
Mangyari po lamang na ireply ang kumpletong detalye ng pasyente para mai-refer
namin sya sa aming partners.

Contact Person:
Contact #s (at least 2 numbers):
Relationship to patient:
FB/Messenger:
Patient Name:
Gender:
Date of Birth:
Address:
Region:
Religion:
Mother's Name & Work:
Father's Name & Work:
Total # of children in the family:
How did you learn about Mabuhay Deseret?:
How did you learn about Smile Train?:
Length of pregnancy:
(Please answer the following with a Yes or No)
Did you have complications during pregnancy?:
Did you have complications during birth?:
Did you smoke during pregnancy?:
Did you drink alcohol during pregnancy?:
Do the siblings or parents have cleft?:
Do other relatives have cleft?:
Patient weight:
Patient height:
Patient's cleft condition (cleft lip only/cleft palate only/cleft lip and palate):
Type of cleft (unilateral or bilateral):
Which side (left/right/both)?:
Done with surgery (yes/no):
What type of surgery (lip surgery/palate surgery/lip & palate surgery/fistula
repair):
Does the patient have other craniofacial deformities?:
What type of abnormality?:
Allergies?:
Philhealth # (of parent):
PWD ID # (of patient):

* Requirements *

Please send photos of these requirements to my FB messenger account: Nathalie

Cardenas Balota
1. Certificate of Indigency from the City/Municipal Social Service Department or
DSWD
2. Philhealth MDR of parents
3. PWD ID of patient
4. Pre-treatment close-up photos: front, right & left side views, intra-oral
5. ST & MDF Patient Release Forms (print, fill-up & sign, then send back the photo
of the signed form)

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Name of Patient:
Address:
Contact Numbers:
Date of Birth:
Name Parents/Guardian:
FB Page of Parent/Guardian:
Medical Condition (Cleft Lip Only, Cleft Palate Only, Cleft Lip and Palate):
Type of Surgery to be Availed (Lip Surgery, Palate Surgery,Lip Revision - with
previous lip surgery, Palate Repair - with previous palate surgery):
Previous Surgery/ies Done(Please list all previous surgery details -
date/hospital/doctor/type of surgery):
Weight of patient (in kg):
Height of patient (in kg):

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Please get in touch with me from MONDAYS to FRIDAYS at 9:00 AM to 4:00 PM only.

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Please secure a schedule for NAM check up sa secretary:

Dr. Larissa Ann Ang Lim
0917-7709670 (Secretary)

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Chinita Abad
May 18-21
June 1-4

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naoperahan na si baby? if yes, kelan?

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Meron ulit surgery mission ngayong June 1-4, 2023 either sa Provincial Hospital ng
Carcar or Danao. Let me know (message nyo ako) if meron sa inyong gusto magpapila.

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Si Nathalie po ito sa Mabuhay Deseret Foundation. Pwede nyo po ba ako i-message sa

FB messenger: Nathalie Cardenas Balota ang name ko sa FB para maibigay ko po ang
mga requirements na need nyo po iprepare para sa opera sa cleft. Hintayin ko po ang
message nyo.

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