Bacolod - Thera Peia Medica Laboratory

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Thera Peia Medica Laboratory & Medical Clinic Co.

Unit 1 , JP & D Hervias Heritage Square Bldg., Burgos Street, Bacolod City
Tel. No. (034) 435-3498 Email Add: thera_peialab@yahoo.com

LABORATORY FORM PRIORITY NUMBER

PATIENT NAME: _______________________________________________________ DATE: __________________

ADDRESS: ____________________________________________________________ INVOICE #: ______________

AGE/SEX/CS: _________________________________________________________ AMOUNT: ______________

CONTACT NUMBER:____________________________________________________

DATE OF BIRTH: _______________________________________________________

REQUESTING PHYSICIAN: _______________________________________________

HISTORY: _________________________________________ LMP: ______________

EXAMINATION ________________________________________________________

PACKAGE 1 PACKAGE 2 PACKAGE 3


CBC CBC CBC
URINALYSIS URINALYSIS URINALYSIS
STOOL EXAMINATION STOOL EXAMINATION STOOL EXAMINATION
CHEST XRAY CHEST XRAY CHEST XRAY
PHYSICAL EXAMINATION PHYSICAL EXAMINATION PHYSICAL EXAMINATION
DRUG TEST DRUG TEST
HBSAG HBSAG
PREGTEST SERUM
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Thera Peia Medica Laboratory & Medical Clinic Co.
Unit 1 , JP & D Hervias Heritage Square Bldg., Burgos Street, Bacolod City
Tel. No. (034) 435-3498 Email Add: thera_peialab@yahoo.com

XRAY FORM PRIORITY NUMBER

PATIENT NAME: _______________________________________________________ DATE: __________________

ADDRESS: ____________________________________________________________ OR #: __________________

AGE/SEX/CS: _________________________________________________________ AMOUNT: ______________

CONTACT NUMBER:____________________________________________________

DATE OF BIRTH: _______________________________________________________

REQUESTING PHYSICIAN: _______________________________________________

EXAMINATION: __________________

LMP: ___________________________

HISTORY: _____________________________________________________________

FILM USED:
TIME TAKEN:
TECHNOLOGIST:

Instructions: ***PLEASE BRING VALID ID

1. Pre-employment Medical Examination will be at:

Thera Peia Medica Laboratory & Medical Clinic Co.

Address: Unit 1, JP & D Hervias Heritage Square Bldg., Burgos Street, Bacolod City

Telephone number: (034) 435-3498

Schedule: Monday – Friday (7:00am to 4:00pm)

Physical exam schedule:

Dr. Edwin J. Miraflor Jr. – Monday to Friday – 10 AM and 2 PM

2. Pay the amount of P975 (female) or Package 3. Tests needed:

o CBC o Physical Exam


o Urinalysis o Drug Test
o Fecalysis o HBsAg screening/ Qualitative Hepa B
o Chest X-ray o Pregnancy Test

Pay the amount of P850 (male) or Package 2. Tests needed:

o CBC o Physical Exam


o Urinalysis o Drug Test
o Fecalysis o HBsAg screening/ Qualitative Hepa B
o Chest X-ray

3. Please claim the official receipt to be submitted during first day of work or once you report to the office. The result will be sent to the company.

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