PAMPANGA MEDICAL SPECIALIST HOSPITAL PAMPANGA MEDICAL SPECIALIST HOSPITAL

San Antonio, Guagua, Pampanga San Antonio, Guagua, Pampanga

pmsh - form no. 14 pmsh - form no. 15

DISCHARGE CLEARANCE SLIP DISCHARGE CLEARANCE SLIP

Name: ASR No.: Name: ASR No.:

Address Room No.: Address Room No.:
Bed No.: Bed No.:
N.O.D.: Date: Issued by : Date:
Time: Time:

Issued by:
Cashier Nurse Station Copy Signature over Printed Name (HEAD NURSE) Guard Copy

PAMPANGA MEDICAL SPECIALIST HOSPITAL PAMPANGA MEDICAL SPECIALIST HOSPITAL

San Antonio, Guagua, Pampanga San Antonio, Guagua, Pampanga

pmsh - form no. 14 pmsh - form no. 15

DISCHARGE CLEARANCE SLIP DISCHARGE CLEARANCE SLIP

Name: ASR No.: Name: ASR No.:

Address Room No.: Address Room No.:
Bed No.: Bed No.:
N.O.D.: Date: Issued by : Date:
Time: Time:

Issued by:
Cashier Nurse Station Copy Signature over Printed Name(HEAD NURSE) Guard Copy