EXAMINING CLINIC’s COPY

Pre – Employment Examination Schedule Form for OPTUM GLOBAL SOLUTIONS

(PHILIPPINES), INC.
Contract Year: January 1, 2022 to December 31, 2022
Date/ Time Issued:
Name: Marianne Grace Urcia Age: 22 Sex: ( ) Male (X) Female
Pre-Employment Exam Schedule: Clinic:

ALL exams must be COMPLETED within one month at the examining clinic and this will be billed to OPTUM GLOBAL
SOLUTIONS (PHILIPPINES), INC.

Basic 4 (Physical Examination, Urinalysis,Chest X-ray, CBC)

9 Panel Drug Test (Shabu, Marijuana, Ecstasy, Barbiturates, Cocaine, Opiates, Benzodiazepine, Phencyclidine,
Methadone)
Basic 4 (Physical Examination, Urinalysis,Chest X-ray, CBC) with 9 Panel Drug Test (Shabu, Marijuana,
Ecstasy, Barbiturates, Cocaine, Opiates, Benzodiazepine, Phencyclidine, Methadone)
Additional Test and Consultation applicable for Clearance after initial PEME: Up to Php 1,200.00 (excess
will be paid by patient)

Reminders for Employees:

- Bring the company ID or any valid ID for proper identification
- Bring your corrective lenses/glass for the visual acuity test
- Bring a pea sized stool sample (this should be collected 2 hours maximum prior to submission)

Clinic Remarks:
- Urinalysis (May be postponed only for menstruating females. Menstruating females are to proceed to return to the clinic
for completion). Is female applicant menstruating now? Yes No
- Chest X-ray PA (waived only for pregnant applicants with Certification from OB)
Is female applicant pregnant at the moment? Yes No

WAIVER (to be signed by the Applicant):

I understand that I am required to complete all medical tests stated in this form within one visit to the designated medical clinic.
I understand that my failure to complete these tests today may result in the rejection of my application for employment with OPTUM
GLOBAL SOLUTIONS (PHILIPPINES), INC. I understand that it is OPTUM GLOBAL SOLUTIONS (PHILIPPINES), INC.’s sole discretion to
accept or reject whatever reasons I may state for non- completion of exams in one visit.

Acknowledgment of Receipt Endorsed by: Exit Signature: Certified Complete:

and agreement to waiver:

Applicant Recruitment Applicant Examining Clinic

 CLIENT’s COPY

Pre - Employment Examination Schedule Form for OPTUM GLOBAL SOLUTIONS

(PHILIPPINES), INC.:
Contract Year: January 1, 2022, to December 31, 2022
Date/ Time Issued:
Name: Marianne Grace Urcia Age: 22 Sex: ( ) Male (X) Female
Pre-Employment Exam Schedule: Clinic:

ALL exams must be COMPLETED within one month at the examining clinic and this will be billed to AIC PHILIPPINE, BILLGOSLING
OUTSOURCING:

Basic 4 (Physical Examination, Urinalysis, Chest X-ray, CBC)

9 Panel Drug Test (Shabu, Marijuana, Ecstasy, Barbiturates, Cocaine, Opiates, Benzodiazepine, Phencyclidine,
Methadone)
Basic 4 (Physical Examination, Urinalysis, Chest X-ray, CBC) with 9 Panel Drug Test (Shabu, Marijuana,
Ecstasy, Barbiturates, Cocaine, Opiates, Benzodiazepine, Phencyclidine, Methadone)
Additional Test and Consultation applicable for Clearance after initial PEME: Up to Php 1,200.00 (excess
will be paid by patient)

Reminders for Employees:

- Bring the company ID or any valid ID for proper identification
- Bring your corrective lenses/glass for the visual acuity test
- Bring a pea sized stool sample (this should be collected 2 hours maximum prior to submission)

Clinic Remarks:
- Urinalysis (May be postponed only for menstruating females. Menstruating females are to proceed to return to the clinic for
completion). Is female applicant menstruating at the moment? Yes No
- Chest X-ray PA (waived only for pregnant applicants with Certification from OB)
Is female applicant pregnant at the moment? Yes No

WAIVER (to be signed by Applicant):

I understand that I am required to complete all medical tests stated in this form within one visit to the designated medical clinic.
I understand that my failure to complete these tests today may result in the rejection of my application for employment with OPTUM
GLOBAL SOLUTIONS (PHILIPPINES), INC. I understand that it is OPTUM GLOBAL SOLUTIONS (PHILIPPINES), INC. ’s sole discretion to
accept or reject whatever reasons I may state for non- completion of exams in one visit.

Acknowledgment of Receipt Endorsed by: Exit Signature: Certified Complete:

and agreement to waiver:

Applicant Recruitment Applicant Examining Clinic

REMINDERS:
1. Please proceed to the clinic at least 20 minutes prior to your appointment schedule
2. Kindly note that all patients with confirmed appointments will be attended on a FIRST COME FIRST SERVE BASIS.
3. Patients with appointments are allowed to enter the clinic premises on their scheduled appointment only.
4. All patients will be required to go through the triage area prior to entering the clinic premises.
5. Companions and visitors are not allowed inside the clinic premises, however, only those accompanying a Senior Citizen and PWD will
be allowed.

FOR CONSULT:
• Please be reminded to bring your doctors request (If for procedure) and available results (if for consultation and fit to work)
FOR PEME:
• Please bring your endorsement / PEME slip during your appointment date

FOR APE / PEME / CONSULT:

• Please bring HMO card (if available) & any 2 VALID IDs

FASTING TIME:
• BLOOD CHEM FASTING: 8-10HRS
• LIPID PROFILE: 10HRS
• UTZ FASTING: 6-8HRS

PLEASE BRING YOUR OWN BLACK PEN as a safety precaution.

• Should there be any changes / cancellations in doctor's schedule, we will advise you a DAY prior your appointment schedule or as soon
as we can.
• For suspected COVID patients during triage assessment, the patient may not be allowed to enter the clinic premises depending on
the severity and will be referred to their HOC.
• For those who completed their 14 days quarantine, please present a copy of your barangay quarantine completion form as proof prior
to accommodation

***No MASK & No FACESHIELD, No Entry. ONLY SURGICAL MASK is allowed inside the clinic. ***

Please be reminded of our 2-3 days TAT in setting an appointment.

For requests to reschedule confirmed appointments, kindly note that there will be a waiting period of 5 to 7 days to secure an open slot as all
schedules for the coming weeks are already taken. We highly encourage patients to comply with their confirmed appointments.

IMPORTANT: For your ONLINE HEALTH MONITORING TRACKER, please scan the QR code below or go to https://www.aventusmedical.net/retail-
clinic/portalat least 1-2 hours prior your scheduled appointment. Kindly take a screenshot of the alert message and present to our triage
personnel or clinic guard on duty: