Warning

Republic of the Philippines

Any false statement knowingly made
PROFESSIONAL REGULATION COMMISSION
hereunder will render the affiant liable
Regional Office No. V
to prosecution for perjury under
Legazpi City
Sec. 2674 of the Revised Administrative
Code as amended
BOARD OF MIDWIFERY
RECORDS OF DELIVERIES HANDLED

Name of Applicant: __________ ____ School: CAMARINES SUR POLYTECHNIC COLLEGES

HOSPITAL CHECK IF SUPERVISED BY THE FACULTY

NAME OF
NAME OF PATIENT ADDRESS DATE CASE HOME
HOSPITAL
NUMBER DELIVERY NAME IN PRINT SIGNATURE DESIGNATION REG. NO.
1.
2.
3.
4.
5.
6.
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8.
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SUTURES

HOSPITAL CHECK IF SUPERVISED BY THE FACULTY

NAME OF
NAME OF PATIENT ADDRESS DATE CASE HOME
HOSPITAL NAME IN PRINT SIGNATURE DESIGNATION REG. NO.
NUMBER DELIVERY
1.
2.
3.
4.
5.

INTRAVENOUS INJECTION

HOSPITAL CHECK IF SUPERVISED BY THE FACULTY

NAME OF
NAME OF PATIENT ADDRESS DATE CASE HOME
HOSPITAL NAME IN PRINT SIGNATURE DESIGNATION REG. NO.
NUMBER DELIVERY
1.
2.
3.
4.
5.

SUBSCRIBED AND SWORN TO before this CERTIFIED CORRECT

at
affiant exhibiting to me his/her Certificate
No. issued at MARILYN N. RIVERA, RM, RN, MAN
on PRINCIPAL

Notary Public Affix doc. stamp