Physician Affiliation

Physician's General Information

Physician Form

Specialization

Sub-Speciality

Name

First Name

Middle Name

Last Name

Phone Number

Mobile Number

Email Address

Birthdate

Gender

Civil Status

Main Hospital Affiliation

Room Number

Clinic Schedule (Days and Time)

Clinic Direct Line/ Telephone Number

Secretary

PRC License Number

Expiration

PHILHEALTH Accreditation Number

Validity - Expiration

Tax Payer ID Number/ TIN

Tax Status: Please check the appropriate box

VAT

NON-VAT

Checkboxes

PCP

PCS

Others

Other Hospital and Clinic Affiliation

Hospital

Room

Clinic Schedule

Clinic Direct Line/ Telephone Number

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NOTE: KINDLY NOTIFY LIFE AND HEALTH ON ANY CHANGES IN YOUR NAME, MOBILE/PHONE NUMBER, HOSPITAL AFFILIATION, CLINIC ADDRESS AS SOON AS POSSIBLE.