Republic of the Philippines

Quezon City
Quezon City Health Department

Order of Payment
Health Certificate

The City Treasurer Bldg.

Miscellaneous Section

Sir / Madam:

Please accept payment from Mr. / Ms. JUDITH ARNALDO BAUTISTA the amount of ₱300.00
Computed as follows:

Name Amount

Health Certificate Fee 613-004 ₱75.00

HIV/AIDS Seminar Fee ₱50.00

Massagist Course Fee ₱0.00

VD Clearance/Smear Fee ₱0.00

Laboratory Fees

Stool Exam ₱65.00

Sputum/Xray Exam ₱110.00

Health Occupancy Permit Fee 605-010 ₱0.00

Total ₱300.00
 RAMONA ASUNCION DG. ABARQUEZ M.D. MPH
Authorized Personnel

Paid under O.R. #:

Date:

Reference No.: M1013713H