REPUBLIC OF THE PHILIPPINES)

PROVINCE OF PANGASINAN )S.S.

CITY OF ALAMINOS )
X------------------------X

SELF SERVING AFFIDAVIT

THAT I, LETICIA T. DELA CRUZ, of legal age, Filipino citizen, married, and
resident of Macatiw, Alaminos City, Pangasinan, after having been duly sworn to in
accordance with law hereby depose and say:

That I was born from parents SPS. VICENTE SABADO TABOY and ELENA LOPEZ
MACATIAG, born on December 7, 1958 in Sual, Pangasinan.

That I contracted marriage with SIVESTRE DELA CRUZ on January 23, 1983 in
San Clemente, Tarlac;

That in my marriage contract, my first name was erroneously entered as

LETECIA, but my true and correct first name is LETICIA;

That I am executing this affidavit to attest to the truth of the foregoing facts and
for any legal intent it may best serve;

IN WITNESS WHEREOF, I have hereunto set my hand this _________________

at Alaminos City, Pangasinan.

LETICIA T DELA CRUZ

Affiant

SUBSCRIBED AND SWORN to before me, this ___________________ at

Alaminos City, Pangasinan.
REPUBLIC OF THE PHILIPPINES)
PROVINCE OF PANGASINAN )S.S.
CITY OF ALAMINOS )
X------------------------X

AFFIDAVIT OF SELF- EMPLOYED PROFESSIONAL

THAT I, MAUREEN AVA P. TESORO, DMD, of legal age, Filipino Citizen,

single, and resident of Paitan West, Sual, Pangasinan, after having been duly sworn to
in accordance with law hereby depose and say:

That I am a Doctor of Dental Medicine with the following details:

PRC……………………………………..0046564
PTR……………………………………..0254623
TIN………………………………………413-553-117-000

That I am a self-employed professional with clinic at G/F EJR Building, Sadsaran

St., Poblacion, Alaminos City, Pangasinan;

That my source of patients are walk-in patients at my clinic;

That the billing rates I demand from my walk-in patients in my clinic is ONE
HUNDRED PESOS, (P100.00) Philippine Currency per consultation and other dental
services and its corresponding fees are listed in separate page (see attached copy which
made an integral part hereof); and my professional rates are as follows:

A. Relatives and family members are pro bono;

B. Colleagues in the profession and their immediate relatives are pro
bono
C. Senior citizens with valid OSCA cards and Persons with Disabilities with
valid PWD card will be VAT-exempt and given 20% discount.
D. Accredited companies and HMO’s (with agreed rates)

That the professional fees per my walk in patient are filed to the Bureau of
Internal Revenue;

That I am executing this affidavit in compliance with the BIR Revenue Regulation
No. 4-2014 dated March 3, 2014.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at

Alaminos City, Pangasinan.
 MAUREEN AVA TESORO, DMD
Affiant

SUBSCRIBED AND SWORN to before me, this ___________________ at

Alaminos City, Pangasinan.

REPUBLIC OF THE PHILIPPINES)

PROVINCE OF PANGASINAN )S.S.
CITY OF ALAMINOS )
X------------------------X

AFFIDAVIT OF SELF- EMPLOYED PROFESSIONAL

THAT I, GLENDA NAVARRO NAVARRETE, of legal age, Filipino Citizen,

single, and resident of Ambabaay, Bani, Pangasinan, after having been duly sworn to in
accordance with law hereby depose and say:

That I am a Doctor of Dental Medicine with the following details:

PRC……………………………………..0043325
PTR……………………………………..9187762
TIN………………………………………262-692-455

That I am a self-employed professional with clinic at Poblacion, Bani,

Pangasinan;

That my source of patients are walk-in patients at my clinic;

That the billing rates I demand from my walk-in patients in my clinic is ONE
HUNDRED PESOS, (P100.00) Philippine Currency per consultation.
That the professional fees per my walk in patient are filed to the Bureau of
Internal Revenue;

That I am executing this affidavit in compliance with the BIR Revenue Regulation
No. 4-2014 dated March 3, 2014.

IN WITNESS WHEREOF, I have hereunto set my hand this ________________ at

Alaminos City, Pangasinan.
 GLENDA NAVARRO NAVARRETE, DMD
Affiant

SUBSCRIBED AND SWORN to before me, this ___________________ at

Alaminos City, Pangasinan.

DENTAL SERVICES AMOUNT

Oral Prophylaxis P 350.00

Light-CuredRestoration 350.00 per surface +P350.00 for
each additional surface
Amalgam Restoration 300.00 per surface +200.00 for
each additional surface
Temporary Filling 250.00 per tooth
Pit and Fissure Sealant 450.00
Fluoridization 1,500.00

Cosmetic Dentistry
Conventional Whitening (U & L) 15,000.00
Light Activated Whitening 20,000.00
Porcelain Laminates 8,000.00 per unit
Composite Resin Laminates 5,000.00 per unit

Root Canal Therapy

Monorooted 3,000.00
Birooted 5,000.00
Trirooted 9,000.00

Fixed Bridge
Plastic 1,500.00
Porcelain 3,000.00
All-ceramic 10,000.00
Complete Denture
Low-end Acrylic Base/Leeformatron/New Ace 8,000.00
High-end Acrylic Base/Ivoclar/Justi/Monalisa 15,000.00
Low-end Acrylic base/Porcelain Pontics 10,000.00
High-end Acrylic Base/Porcelain Pontics 15,000.00

Assembled RPD (Anterior or Posterior only) 2,500.00

Thermoplastic RPD (anterior or Posterior only) 15,000.00
One-Piece Casted RPD (anterior or Posterior only) 8,500.00
Combination of One-Piece Casted RPD with
 Thermoplastic Base 20,000.00

Extraction 3 00.00
Odontectomy 5,000.00
Alveoloplasty 2,500.00
Dowel Post 2,500.00

Orthodontic Case 35,000.00 minimum

Dental check up and consultation 100.00