DAVAO MEDICAL SCHOOL FOUNDATION

DAVAO CITY, PHILIPPINES

CLERK____________________________________ _____________________________________ ________________________

GOVERNMENT HOSPITAL DATE

NORMAL SPONTANEOUS DELIVERIES ( 10 )

Case Name Address Age Date Final Diagnosis Attending
No. Delivered Physician

CHECKED:
________________________________________________ ____________________________________
RESIDENT/CONSULTANT PRECEPTOR CLERK’S COORDINATOR

_____________________________________________
DEAN, DAVAO MEDICAL SCHOOL FOUNDATION

NOTE: Must be submitted to the Registrar’s Office during the signing of clearance.
All signatures must have a printed name.
 DAVAO MEDICAL SCHOOL FOUNDATION
DAVAO CITY, PHILIPPINES

CLERK____________________________________ _____________________________________ ________________________

GOVERNMENT HOSPITAL DATE

MAJOR SURGERIES ASSISTED ( 6 )

(OB & GYN)
Case Name Address Age Date Final Diagnosis Attending
No. Performed Physician

CHECKED:
________________________________________________ ____________________________________
RESIDENT/CONSULTANT PRECEPTOR CLERK’S COORDINATOR

_____________________________________________
DEAN, DAVAO MEDICAL SCHOOL FOUNDATION

NOTE: Must be submitted to the Registrar’s Office during the signing of clearance.
All signatures must have a printed name.
 DAVAO MEDICAL SCHOOL FOUNDATION
DAVAO CITY, PHILIPPINES

CLERK____________________________________ _____________________________________ ________________________

GOVERNMENT HOSPITAL DATE

FOLEY CATHETER / STRAIGHT CATHETER INSERTION ( 3 )

Case Name Address Age Date Final Diagnosis Attending
No. Delivered Physician

IVF INSERTION ( 3 )
Case Name Address Age Date Final Diagnosis Attending
No. Delivered Physician

CHECKED:
________________________________________________ ____________________________________
RESIDENT/CONSULTANT PRECEPTOR CLERK’S COORDINATOR

_____________________________________________
DEAN, DAVAO MEDICAL SCHOOL FOUNDATION

NOTE: Must be submitted to the Registrar’s Office during the signing of clearance.
All signatures must have a printed name.
 DAVAO MEDICAL SCHOOL FOUNDATION
DAVAO CITY, PHILIPPINES

CLERK____________________________________ _____________________________________ ________________________

GOVERNMENT HOSPITAL DATE

PAP SMEAR / GRAM STAIN ( 10 )

Case Name Address Age Date Final Diagnosis Attending
No. Performed Physician

CHECKED:
________________________________________________ ____________________________________
RESIDENT/CONSULTANT PRECEPTOR CLERK’S COORDINATOR

_____________________________________________
DEAN, DAVAO MEDICAL SCHOOL FOUNDATION

NOTE: Must be submitted to the Registrar’s Office during the signing of clearance.
All signatures must have a printed name.