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ARMED FORCES OF THE PHILIPPINES MEDICAL CENTER

VICTORIANO LUNA GENERAL HOSPITAL


Camp Colonel Victoriano K Luna, VLuna Avenue, Quezon City

Surgical Intensive Care Unit


Date: ________________

Rank/Patient’s Name: _______________________________ Age: ______ Reg#: _______________


Date Admitted: _______________________ Date Discharged: ____________________
Admitting Diagnosis: ________________________________________________________________
________________________________________________________________
Final Diagnosis: ___________________________________________________________________
________________________________________________________________
________________________________________________________________
________________________________________________________________
Attending Physician: ___________________________

DISCHARGE INSTRUCTIONS

Home Medications:

Other Instructions/ Health Teachings:

Follow-up Checkup:

____________________ __________________
Received by: NOD

__________________
Date

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