Updated ROJoson Medical Clinic Form – January 3, 2016
REYNALDO O. JOSON, M.D.
Master of Science in Clinical Medicine; Master in Health Profession Education
ROJoson Medical Clinic
Patient’s General Data
(Last name) (First name) (Middle name)
Birthday ___________Age ____Sr. Citizen TIN ______________Sex ___ Civil Status ________
Occupation _________________ Address ___________________________________________
Tel No. ______________Cell No. ____________________ Email _________________________
Relative _______________________ Relationship ________________ Cell No. _____________
Referred by _________________ Personal Account ___Health Insurance (specify) _________
Patient’s Declaration of Health Information (Pls. fill and sign below.)
Date of consult / declaration of information:
Primary reason for consult:
When symptom/s first noted:
Brief description of characteristics of present symptoms:
Previous medical consult and treatment (if yes, give details and provide photocopies of reports):
Taking blood thinning drugs such as aspirin, coumadin, clopidogrel and other drugs?
Known existing / past disease/s (if yes, give details):
I consult with an understanding and acceptance of the Policies and Procedures of ROJoson Medical Clinic explained and published in ttps://sites.google.com/site/rojosonmedicalclinic.
Medicine is not an exact science! Medicine is a science of uncertainty and an art of probability! (Sir William Osler) I practice my medical profession factoring in the above precepts.
I don’t guarantee or give warranty for successful outcomes in my medical management.
Nevertheless, I do my utmost best in managing my patients so as to promote successful outcomes (resolution of the health problem with minimal side-effects as much as possible).
Reynaldo O. Joson, MD
Printed name and signature of patient or guardian (MUST accomplish!)
Medical Specialties of Dr. Reynaldo O. Joson
General Medicine; General Surgery; Surgical Oncology;
Head and Neck, Thyroid, Breast, Abdomen, Gallbladder, Stomach, Intestines, Hernia, Skin and Soft Tissue Disorders
(Do NOT fill below this line.)