Escolar Documentos
Profissional Documentos
Cultura Documentos
2. Complete detailed history of incident and diagnosis: (please indicate if due to sickness or to
accident): Date of onset, what happened, who he went to for treatment, follow-ups, etc.
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________________________________________________________
________________________________________________________
4. Please state your findings and present visual acuity of the affected eye:
_______________________________________________________
_______________________________________________________
_______________________________________________________
5. Based on patient’s present visual acuity, will patient’s vision improve at a later date? If yes, in
what way will improve? When will improvement occur?
________________________________________________________
________________________________________________________
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________________________________________________________
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Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
MCPO Box 1437, Makati City, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph
6. Please indicate your latest assessment of patient’s vision of the affected eye. (please check 2
for each eye)
DECLARATION
I hereby certify that the above statements and facts are true and that I have not withheld any
material information in connection with this confinement.
____________________ ______________________________________________
Name of doctor, Opthalmologist
Date Physician’s Signature Over Printed Name
Specialization :
License # :
Contact #s:
Pioneer House Makati, 108 Paseo de Roxas, Legaspi Village, Makati City 1229, Philippines
MCPO Box 1437, Makati City, Philippines
Tel: +63 2 812 7777 • Fax: +63 2 817 1461 • www.pioneer.com.ph