RMCI Anuual PE

Annual PE Form

Please fill this form with all honesty. This serves as your official medical record.
* Required

Appoint Date

Date *

First Name *

Middle Name

Last Name *

Suffix

Company *

Dear Patient Partner,

YOU ARE REQUIRED TO PROVIDE TRUTHFUL INFORMATION ABOUT YOUR HEALTH CONDITION AND POSSIBLE EXPOSURE.

Pursuant to the provisions of the Data Privacy Act of 2012, I hereby give my free and voluntary consent for Riverside Medical Center, Inc., (owner and operator of the Una Konsulta), its staff, personnel, agents or authorized representatives for the collection, use, sharing and transmittal by any means and processing of my personal information, medical information or privileged information as set out in my Riverside Medical Center, Inc. Data forms, records, medical diagnosis, medical results and findings, and/or any other document or media provided by me or already possessed by Riverside Medical Center, Inc., for purposes relevant to my consultation, diagnosis, treatment, tests or for any other instances mandated by law.

Yes

Age *

Contact Number *

Sex *

Civil Status *

Address *

Nature of Examination *

Do you have the following symptoms? (May ginabatyag ka bala nga mga sintoma?) *

Medical History *

Allergies *

Vaccination History *

Last Menstrual Period

For Females (pregnancy/live births)

Personal/Social History: Smoker? *

How many sticks per day, and for how many years?

Personal/Social History: Alcoholic Beverage Drinker? *

Mode of Payment *