ROJoson Medical Clinic Form – 16jan29

Updated ROJoson Medical Clinic Form – 16jan29


Added “Disclaimer.”




Master of Science in Clinical Medicine; Master in Health Profession Education

ROJoson Medical Clinic

Patient’s General Data

Name _________________________________________________________________________

                    (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 (Pls. read and ask before coming to the Clinic.)

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.)








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