AMERICAN BIO-CLINICAL LABORATORIES, INT’L

CLIENT PROFILE
CLIENT CODE: TERRITORY/AREA:
Ownership: Institutional type:
Private Hospital Multi Clinic Medical Doctor
Government Clinic/Health Center Corporation/Agency Others (Specify) Click here to enter text.

BUSINESS NAME: Click here to enter text.

BUSINESS ADDRESS: Click here to enter text.
TIN NUMBER: Click here to enter text.
AUTHORIZED SIGNATORIES FOR CONTRACT:
FULL NAME POSITION
1) Click here to enter text. Click here to enter text.
2) Click here to enter text. Click here to enter text.
3) Click here to enter text. Click here to enter text.
Clinic/Branch Head: Click here to enter text. Birthdate: Click here to enter text.

FOR BILLING/PAYMENT CONCERNS:

FULL NAME POSITION CONTACT NUMBER/S
1) Click here to enter text. Click here to enter text. Click here to enter text.
2) Click here to enter text. Click here to enter text. Click here to enter text.
BILLING SCHEDULE:
□Daily □Semi-Monthly □Special Arrangement (Specify)
□Weekly □Monthly
PAYMENT SCHEDULE:
□COD □15 Days □Special Arrangement (Specify)
□7 Days □30 Days
Fee Schedule Assignment (to be filled up by ABC Lab):

LABORATORY DEPARTMENT
Pathologist: Click here to enter text. Birthdate: Click here to enter text.
CMT/Laboratory OIC: Click here to enter text. Birthdate: Click here to enter text.
Authorized Contact Details for ABC Laboratory Test Reports/Advisories:
Email: Click here to enter text.
Landline: Click here to enter text. Mobile: Click here to enter text.
SPECIMEN PICK-UP REQUIREMENTS
Daily On-Call Special Arrangement (Specify) Click here to enter text.
RELEASING OF LABORATORY TEST REPORT
Delivered by Courier Internet Reporting Special Arrangement (Specify) Click here to enter text.

Prepared By: Processed By: Checked By: Approved By:

_______________________ _______________________ _______________________ _______________________

Sales & Marketing Rep. Client Service Sales & Marketing Manager Finance Officer
Date:_________ Date:_________ Date:_________ Date:_________

RECORDS OF UPDATE
DATE UPDATES UPDATED BY: APPROVED BY:

FM-MGR-401 Effectivity November 25, 2019 Issue 3, Rev. 0 Page 1 of 2 5/7/2024 6:38:36 AM
MASTER COPY | 5/7/2024 CONTROLLED | 5/7/2024
 AMERICAN BIO-CLINICAL LABORATORIES, INT’L
SMR CS SMM FO

ASSIGNED SALES & MARKETING REPRESENTATIVE

FROM TO NAME

FM-MGR-401 Effectivity November 25, 2019 Issue 3, Rev. 0 Page 2 of 2 5/7/2024 6:38:36 AM
MASTER COPY | 5/7/2024 CONTROLLED | 5/7/2024