PROFESSIONAL REGULATION COMMISSION

Manila

BOARD OF MIDWIFERY
RECORD OF DELIVERIES HANDLED

NAME: SCHOOL:

Supervised by
Name of Patient Address Date Name of Hospital Hospital Case Number Check if Home Delivery Name in Print Signature Designation Registration Number
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 SUTURING
Supervised by
Name of Patient Address Date Name of Hospital Hospital Case Number Check if Home Delivery Name in Print Signature Designation Registration Number
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INTRAVENOUS INSERTIONS
Supervised by
Name of Patient Address Date Name of Hospital Hospital Case Number Check if Home Delivery Name in Print Signature Designation Registration Number
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CERTIFIED CORRECT:

CHIEF OF HOSPITAL

SUBSCRIBED AND SWORN to before me this _____________ day of ___________ at _________________, Philippines. Affiant exhibited to me his/her Community Tax Certificate Number ____________
issued on _____________________________________ at ________________________.

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Notary Public