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Nursing Form and Others
NUrse

August 01, 2013
_____________________________

Dear _________________________,

Mercury Drug will hold Bantay Kalusugan “Iwas Trangkaso” flu vaccination/free consult for 6 consecutive Saturdays, August 17-Sept 21, 2013, 10 am-7 pm at participating stores throughout the country.

Join us in 3 easy steps: 1. Confirm participation by sending your HHC Case Manager your contact details. 2. Follow flu vaccine administration procedure. 3. Receive your honorarium by sending your Case Manager right after event the needed forms.

I. Confirm participation by sending your Case Manager (Name):Maria Lourdes L. Priela, Mobile: 0922-890-8704 the ff:

_______________________________________________________________________
Your Name: First name, Mother’s maiden name, last name MD ____or RN ____
Complete Address: ________________________________________________________________________
Sex: __ Nationality: _____________Marital Status ________Birthdate ______________
Birthplace: ____________Sun Mobile: ______________ Other Mobile: ___________
PRC License Number _________Expiry Date: ______________TIN: ________________
E-mail _________________________________________________
Put a check: ___Metro bank _____BPI _____BDO
Account Name___________________________________________________________
Account No: _____________________Bank Branch_____________________________

Via text, fax 920 1445 or e mail vaccinator@homehealthcare.com.ph

Reply to text reminders one week, 24, 4, and 2 hours before event and notify Mercury store manager/ your HHC Case Manager upon arrival in branch. Be in medical gown / scrub suits with your stethoscope/ BP apparatus on time. If you cannot make it, please find your reliever.

II. Follow flu vaccine administration procedure:

1. MD screens patients/quick consult using “Influenza Vaccination Consent Form”. Check that all blanks filled and sign above printed name. 2.
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