Note:
Accomplished form shall be submitted to Konsulta Provider
(Ang kumpletong form ay dapay isumite sa tagapagbigay ng Kunsulta) Philhealth Identification Number of Patient: __________________
ELECTRONIC PRESCRIPTION SLIP (EPRESS)
To be filled-out by the facility (Pupunan ng Pasilidad)
HCI NAME: Case No.: HCI Accreditation No. Transaction No.: ELECTRONIC PRESCRIPTION SLIP (EPRESS)
Santol Primary Care Facility P01034151
PIN(PhilHealth Identification Number): Membership Category: Membership Type: MEMBER
DEPENDENT To be filled-out by the facility (Pupunan ng Pasilidad)
Patient Name(Pangalan ng pasyente) Age (Edad): Contact No. (Numero ng Telepono): HCI NAME: Case No.: HCI Accreditation No. Transaction No.:
Santol Primary Care Facility P01034151
PIN(PhilHealth Identification Number): Membership Category: Membership Type: MEMBER
DEPENDENT
USE GENERIC NAME Patient Name(Pangalan ng pasyente) Age (Edad): Contact No. (Numero ng Telepono):
USE GENERIC NAME
Physician: DR. ROBEN L. LEDDA JR
PRC LIC No.: 142086
Next Dispensing Date: _________ PTR No.:____________________
(Petsa ng susunod na bigay na gamot) S2.No.______________________
Physician: DR. ROBEN L. LEDDA JR
PRC LIC No.: 142086
Note:
Next Dispensing Date: _________ PTR No.:____________________
To be filled-out by the patient (Pupunan ng Pasyente) (Petsa ng susunod na bigay na gamot) S2.No.______________________
Did you received the above-mentioned medicines?
Note:
(Natanggap mo ba ang mga gamot na nabanggit?) Yes(Oo) _No(Hindi)
To be filled-out by the patient (Pupunan ng Pasyente)
Are you satisfied with the medicines you recieved?
(Nsiyahan kaba sa mga gamot na natangap mo?) Happy Neutral Sad
Did you received the above-mentioned medicines?
(Natanggap mo ba ang mga gamot na nabanggit?) Yes(Oo) _No(Hindi)
For your comment, suggestion or complaint:
(Para sa iyong komento, mungkahi o reklamo):
Are you satisfied with the medicines you recieved?
(Nsiyahan kaba sa mga gamot na natangap mo?) Happy Neutral Sad
For your comment, suggestion or complaint:
(Para sa iyong komento, mungkahi o reklamo):
Note:
Accomplished form shall be submitted to Konsulta Provider
(Ang kumpletong form ay dapay isumite sa tagapagbigay ng Kunsulta) Philhealth Identification Number of Patient: __________________
