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    Medicard Philippines, Inc.: Clr-Fo-037 Rev.00 22 Feb 2018

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    Euler Mendoza
    This document is an outpatient consultation form from MediCard Philippines for patient Euler Benedict Mendoza. It documents a visit on August 26, 2021 to Mercy Community Hospital to see Dr. Armando Isla Jr. for a chief complaint of ongoing cough for over 6 months with tight throat, throat pain and ear pain. The form includes sections for history, vital signs, physical exam, diagnosis, tests, treatment plan and signatures of the patient and physician.

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    © All Rights Reserved
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    Medicard Philippines, Inc.: Clr-Fo-037 Rev.00 22 Feb 2018

    Uploaded by

    Euler Mendoza
    63 views1 page
    This document is an outpatient consultation form from MediCard Philippines for patient Euler Benedict Mendoza. It documents a visit on August 26, 2021 to Mercy Community Hospital to see Dr. Armando Isla Jr. for a chief complaint of ongoing cough for over 6 months with tight throat, throat pain and ear pain. The form includes sections for history, vital signs, physical exam, diagnosis, tests, treatment plan and signatures of the patient and physician.

    Original Title

    CONSULT_FORM_MACEII1168505

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    This document is an outpatient consultation form from MediCard Philippines for patient Euler Benedict Mendoza. It documents a visit on August 26, 2021 to Mercy Community Hospital to see Dr. Armando Isla Jr. for a chief complaint of ongoing cough for over 6 months with tight throat, throat pain and ear pain. The form includes sections for history, vital signs, physical exam, diagnosis, tests, treatment plan and signatures of the patient and physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
    Download as pdf or txt
    63 views1 page

    Medicard Philippines, Inc.: Clr-Fo-037 Rev.00 22 Feb 2018

    Uploaded by

    Euler Mendoza
    This document is an outpatient consultation form from MediCard Philippines for patient Euler Benedict Mendoza. It documents a visit on August 26, 2021 to Mercy Community Hospital to see Dr. Armando Isla Jr. for a chief complaint of ongoing cough for over 6 months with tight throat, throat pain and ear pain. The form includes sections for history, vital signs, physical exam, diagnosis, tests, treatment plan and signatures of the patient and physician.

    Copyright:

    © All Rights Reserved
    Download as PDF, TXT or read online from Scribd
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    CLR-FO-037

    MediCard Philippines, Inc. Rev.00


    Head Office: 8th Floor, The World Centre Building, 22 FEB 2018
    330 Sen. Gil Puyat Ave, Makati City 1200
    Tel. No.: 8884-9999 Fax No.: 8810-3855; 8848-6454
    Website: www.medicardphils.com E-mail: inquiry@medicardphils.com

    Out - Patient Consultation Form


    Date This form is valid Aug 26, 2021 to Aug 28, 2021 only.
    Doctor: ISLA JR., ARMANDO Hospital: MERCY COMMUNITY HOSPITAL
    Name of Patient: MENDOZA, EULER BENEDICT Member ID: 34502112 Age: 26 Sex: MALE
    Company: MABUHAY VINYL CORPORATION
    Effectivity Date: 2021-07-01 Validity Date: 2022-06-30
    MACE Reference No: MACEII1168505

    Chief Complaint:
    Ongoing cough for more than 6 months, tight throat, throat and ear pain (left)

    History of Present Illness:

    Past / Family History:

    Review of Systems (ROS)

    Vital Signs : BP: HR: RR: Temp:


    Physical Examination:

    Primary Diagnosis / Working Impression: Prescribed Test/s for Primary Diagnosis:

    ICD 10 CODE:
    Other Diagnosis Contributory to Chief Complaint: Prescribed Test/s for Other Diagnosis:

    Other Diagnosis Non-Contributory to Chief Complaint: Prescribed Test/s for Other Diagnosis:

    Type of illness (if applicable): Congenital Maternity Medico Legal


    Plan of Management/Notes:

    Procedure(s) Done in Clinic:


    Approval No.:

    CONSENT:The patient or his/her authorized representative hereby consents (if patient cannot sign) to the processing and disclosure of the patient’s information by MediCard, its representatives, and its accredited healthcare providers which is
    necessary for the assessment of the patient’s coverage and the fulfillment of its obligations as health care provider, including treatment of illnesses. Consent is also given to share utilization data (for corporate health program) with the Principal
    Member’s Company for the proper administration of its health benefits program and medical results (for company endorsed patient) with the patients endorsing company.
    Withholding or withdrawal of such Consent shall relieve us from our obligation to deliver the appropriate services to the patient.
    The undersigned declares that he has full authority to sign and further acknowledges that the patient is afforded with certain rights and protection in accordance with Republic Act 10173 also known as the Data Privacy Act of 2012 and that he
    may visit www.medicardphils.com/privacy or email privacy@medicardphils.com for more information.

    Signature of Patient/Member Signature of Attending Physician

    Generated by MENDOZA, EULER BENEDICT On 08262021

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