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1-Medicard Referral Slip

1) The document is a pre-employment medical examination schedule form from East West Banking Corporation that lists the required medical procedures and important reminders for applicants. 2) The medical procedures include a physical examination, complete blood count, urinalysis, fecalysis, and chest x-ray, with drug tests billed directly to the bank. 3) It provides contact information for questions and specifies that completed results and billing should be forwarded to the bank's office in Taguig City.

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Mark Nesty
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1K views1 page

1-Medicard Referral Slip

1) The document is a pre-employment medical examination schedule form from East West Banking Corporation that lists the required medical procedures and important reminders for applicants. 2) The medical procedures include a physical examination, complete blood count, urinalysis, fecalysis, and chest x-ray, with drug tests billed directly to the bank. 3) It provides contact information for questions and specifies that completed results and billing should be forwarded to the bank's office in Taguig City.

Uploaded by

Mark Nesty
Copyright
© © All Rights Reserved
We take content rights seriously. If you suspect this is your content, claim it here.
Available Formats
Download as PDF, TXT or read online on Scribd
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EAST WEST BANKING CORPORATION

PRE-EMPLOYMENT MEDICAL EXAMINATION SCHEDULE FORM

Date Issued: _________________________ Valid Until: _________________________

Name: ______________________________ Age: _____ Sex:  Male  Female


Pre-Employment Medical Procedures:
1. Complete Physical Examination (PE) 5. Chest X-ray (CXR)
2. Complete Blood Count (CBC) 6. Drug Test - billed directly to EAST WEST
3. Urinalysis (UA) BANKING CORPORATION (monthly
4. Fecalysis (FA) MOP/Billing)

Important Reminders:
 This form may be presented to any Medicard accredited clinic/facility (please refer below for the address)
together with any valid government issued ID.
 For Urinalysis, urine collection should be done midstream. (Female can submit a specimen at least 5-7 days
after last day of menstruation).
 For Fecalysis, collect pea size stool specimen and place it in a clean container. Specimen should be
submitted to the laboratory within 2 hours after collection.
 No fees will be collected from the patient. PME costs (Basic 5) are charged thru Medicard.
 Repeat examination/clearances (i.e repeat urinalysis, pulmo clearance, cardio clearance) will be shouldered
by the patient.
 Once the examination is complete, the Confirmation of Pre-employment will be signed and keep by the
Medicard Nurse on Duty for attachment to Drug Test Billing.
 All hard copy of results and billing should be forwarded to: 3/F The Beaufort, 5th Ave. cor. 23rd Street
Bonifacio Global City, Taguig City.
 Contact Persons: Ejay Lemoncito [email protected]
Ayeth Combras [email protected]

_______________________________ _________________________________
Applicant’s Signature Authorized HR Representative Signature

___________________________________________________________
Confirmation of Pre-employment Medical Examination: EAST WEST BANKING CORPORATION
(Once the above examination is complete, detach this portion, attach to Billing and send to EastWest Bank HR)

Applicant’s Name: ________________________________ Date: _________________ Time: _______________

Applicant’s Signature: _____________________________ Nurse-on-Duty’s Signature: _____________________

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