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Form 1
Form 1
Department of Health
HEALTH FACILITIES AND SERVICES REGULATORY BUREAU
DOH-HFSRB-QOP-01-Form1
BARANGAY AGLAYAN LYING - IN CLINIC AND DIAGNOSTIC CENTER
Name of Health Facility (HF) or Service Provider :
HF Address : NARRA ST. PUROK 3 AGLAYAN
No. & Street Barangay
District
MALAYBALAY BUKIDNON X
City/Municipality Province
Region
Telephone No 088-813-0943 Fax No : N/A E-mail address aglayanbalc2013@yahoo.com
Acknowledgement
Signature
known to me to be the same person/s who executed the foregoing instrument and they acknowledge to me that the
IN WITNESS WHEREOF, I have hereunto set my hands this ____day of ________________, 20___
DOH-HFSRB-QOP-01 Form1
Rev:00
3/1/2019
Page 2 of 3
DOH-HFSRB-QOP-01 Form1
Rev:00
3/1/2019
Page 3 of 3