ATT - 1427780368982 - RM Final 2015

PROFESSIONAL REGULATION COMMISSION
Manila
BOARD OF MIDWIFERY
PRC FORM No. 106

(Revised January 2011)
Record of Actual Deliveries Handled

Record of Actual Delivery Handled
Please chec(CONTINUED NEXT PAGE)___________Health

and Allied Medical Sciencesicense Number:
___________________________
Expiry Date : _____k if
Name of Applicant:
MARK DAVID MENDIOLA TABLIZO
School:
OURapplicant
LADY OFis:
FATIMA UNIVERSITY (VALENZUELA)
Graduate Midwife
Registered Nurse
Name and Address of

Patient
1. Gemma Tumampil Agonan
29 Metro Height Culiat Quezon
City
Case No
Complete Diagnosis
(Gravida, Para)
Date &
Time
Performed
Full Name, Address of Facility &

Contact Number
586046
Gravida 6 Para 6 (6006) Pregnancy Uterine 38-39 weeks, Cephalic, Left Occiput Anterior,
Delivered via Normal spontaneous delivery to Alive Boy, (Birth weight: 3425 grams, Birth
Length: 49cm), APGAR Score 8,9, Perineal Support
January 12,
2015
6:59 AM
Gravida 3 Para 3 (3003) Pregnancy Uterine 39- 40 weeks, Cephalic, Left Occiput Anterior,
length:49cm), APGAR Score 8,9, repair of 1st degree perineal laceration under local
anesthesia
length: 50.5cm), APGAR Score 8,9, Perineal Support
Check if
Home
Delivery
Supervised by
Printed Name
and Contact
No.
Position /
Designation
Dr. Jose Fabella Memorial Hospital,

Lope De Vega Street Sta. Cruz Manila
7345561-65
Ma. Victoria A.
Barretto
09258218478
Midwife II
0133347/
August 13,
2015
January 16,
2015
9:04 AM

7345561-65
Ma. Victoria A.
Barretto
09258218478
Midwife II
0133347/
August 13,
2015
January 26,
2015
4:39 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
Signature
License No
/ Expiry
Date
2. Lannie Napoles Albano

5999 Sitio San Juan, Baclaran,
Paranaque City
599134
3. Melona Mancile
1038 Del Pilar St. Makati City
600548
4. Marilyn Tolentino
Blk 30 Lot13 phase 4 Soldier
Hills 4, Molino, Bacoor, Cavite
600757
Gravida 6 Para6 (6006) Pregnancy Uterine 39-40 weeks, Cephalic, Left Occiput Anterior,
length: 49cm), APGAR Score 8,9, Perineal Support
January 27,
2015
10:42 PM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
597611
Gravida 4 Para 4 (4004) Pregnancy Uterine 40-41 weeks, Cephalic, Right Occiput Anterior,
January 28,
2015
10:28 PM

7345561
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
600501
Delivered via Normal spontaneous delivery to Alive Girl, (Birth weight: 2340 grams, Birth
February 9,
2015
6:09 PM

7345561-65
Ma. Victoria A.
Barretto
09258218478
Midwife II
0133347/
August 13,
2015
602314
Delivered spontaneously to Alive Boy, (Birth weight: 3095 grams, Birth Length: 46cm),
APGAR Score 8,9 repair of 1st degree perineal laceration under local anesthesia
February
10, 2015
4:12 PM

7345561-65
Ma. Victoria A.
Barretto
09258218478
Midwife II
0133347/
August 13,
2015
Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39weeks, Cephalic, Right Occiput Anterior,
length: 48cm) APGAR Score 8,9, Perineal Support
length: 49cm), APGAR Score 8,9, repair of 1st degree perineal laceration under local
anesthesia
February
13, 2015
2:35 PM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
February
17, 2015
1:15 AM

7345561
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
596311
Gravida 4 Para 4 (4004) Pregnancy Uterine 38-39 weeks, Cephalic, Right Occiput
Anterior, Delivered via Normal spontaneous delivery to Alive Boy, (Birth weight: 2975
grams, Birth length: 52cm), APGAR Score 8,9, Perineal Support
February
18, 2015
10:06 PM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
598773
February
20, 2015
1:40 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
590519
Gravida 2 Para 2 (2002) Pregnancy Uterine 37 weeks, Cephalic, Left Occiput Anterior,
anesthesia
February
21, 2015
11:08 PM

7345561
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
604203
February
23, 2015
11:36 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
5. Sonia Caya
113 Tejeros Rosario, Cavite
6. Marlita Eupan Role
Camp Orasan Novaliches,
Quezon City
7. Violeta Mendoza
#5 AC Bangayan St. San
Antonio Subd., Quezon City
8. Precious Caasi
Balete St. Ilaya, Las PInas City
9. Roselyn Dunghao
TS Cruz Alwanba II, Las Pinas
City
10. Cristy Lanzarote
B 19 Gloria compound Pilar
Village, Las Pinas City
11. Rosemarie Bognot
Marquez
12 B Bagong Buhay St.
Baclaran, Paranaque City
12. April Diwata
16 MC Ignacio St. Roces Ave,
Quezon City
13. Sheryll Loreno
Tanigue St. Samatad,
Caloocan City
594043
603533
Name and Address of

Patient
14. Jona Tijamo
Blk P. Ext. San Simon,
Dasmarinas Cavite
15. Maristhel Compra Zabala
B26 L5 Las Palmas Subd.
Cagpombo, Sta. Maria,
Bulacan
16. Glenda Apostol Bediones
Brgy. 10A Aplaya Munti,
Sta.Cruz, Cavite
17. Grace Rostata Baurosa
20 Enero St. Purok 2Silverio
Compound, San Isidro,
Paranaque City
18. Edna Garcia
55 Jacinto St., Caloocan City
19. Rissa G. Naga
005 Bernabe Compound
Pulang Luoa, Las Pinas City
20. Maritess Sabillano
Hontiveros Compound,
Paranaque City
Note:
Case No
Complete Diagnosis
(Gravida, Para)
Date &
Time
Performed

Contact Number
604734
length: 48cm), APGAR Score 8,9, repair of 2nd degree perineal laceration under local
anesthesia
February
25, 2015
6:21 AM
606148
602268
Check if
Home
Delivery
Supervised by
Printed Name
and Contact
No.
Position /
Designation

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
March 4,
2015
6:15 PM

7345561-65
Joebell A.
Gerona
09055926156
Midwife II
0133741/
August 25,
2016
March 5,
2015
6:18 PM

7345561-65
Mary Grace M.
Mansilungan
09175689659
Midwife III
0119993/
April 16,
2015
606261
anesthesia
March 6,
2015
8:23 PM

7345561-65
Mary Grace M.
Mansilungan
09175689659
Midwife III
0119993/
April 16,
2015
606390
anesthesia
March 9,
2015
12:19 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
601449
March 10,
2015
10:48 PM

7345561
Joebell A.
Gerona
09055926156
Midwife II
0133741/
August 25,
2016
607013
March 12,
2015
10:51 PM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17,
2015
(1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant exhibiting to me his/her Residence
Certificate No. __________________________ issued at _____________________________on_______________________________.
CERTIFIED CORRECT:
Affix
Administering Officer or Notary Public
Documentary
Stamp
Signature: __________________________________________________
___________________________
Printed Name:
Designation:
License Number:
Expiry Date :
Date:
Signature
License No
/ Expiry
Date

Manila
BOARD OF MIDWIFERY
PRC FORM No. 107


Record of Actual Suturing of Lacerations Handled
___________________________
Name of Applicant:
MARK DAVID MENDIOLA TABLIZO
School:
applicant
is: FATIMA UNIVERSITY (VALENZUELA)
OUR
LADY OF
Graduate Midwife
Name and Address of

Patient
1. Roselyn Dunghao
TS Cruz Alwanba II, Las PInas
City
Case
No
Complete Diagnosis
(Gravida, Para)
Date & Time

Performed

Contact Number
603533
Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39 weeks, Cephalic, Right

Occiput Anterior, Delivered via Normal spontaneous delivery to Alive Girl,
(Birth weight: 3045 grams, Birth length: 49cm), APGAR Score 8,9,
repair of 1st degree perineal laceration under local anesthesia
February 17,
2015
1:29 AM

7345561-65
Check if
Home
Delivery
Registered
Nurse
Supervised by
Printed Name
and Contact
No.
Position /
Designation
Rana Lorraine D.
Racca
09175876081
Midwife II
Signature
License
No / Expiry
Date
0138397/
April 17, 2015
Name and Address of

Patient
2. April Diwata
16 MC Ignacio St. Roces Ave,
Quezon City
3. Jona Tijamo
Blk P. Ext. San Simon,
Dasmarinas Cavite
5.
Edna Garcia
55 Jacinto St., Caloocan City
Complete Diagnosis
(Gravida, Para)
Date & Time

Performed

Contact Number
February 21,
2015
11:21 PM
Check if
Home
Delivery
Supervised by
Printed Name
and Contact
No.
Position /
Designation

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17, 2015
February 25,
2015
6:34 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/
April 17, 2015
606261
Gravida 3 Para 3 (3003) Pregnancy Uterine 38-39 weeks, Cephalic, Left

Occiput Anterior, Delivered via Normal spontaneous delivery to Alive Boy,
March 6,
2015
8:34 PM

7345561-65
Mary Grace M.
Mansilungan
09175689659
Midwife III
0119993/
April 16, 2015
606390

March 9,
2015
12:31 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/ A
pril 17, 2015
590519
604734
4. Grace Rostata Baurosa

20 Enero St. Purok 2Silverio
Compound, San Isidro,
Paranaque City
Note:
Case
No
Gravida 2 Para 2 (2002) Pregnancy Uterine 37 weeks, Cephalic, Left

repair of 2nd degree perineal laceration under local anesthesia
Signature

(2) For registered midwives / Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on
Suturing of Perineal lacerations to the Board pursuant to Board Resolution No. 100 s 1993, dated December 1, 1993.
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant

exhibiting to me his/her Residence Certificate No. __________________________ issued at _________________________on_______________________________.
CERTIFIED CORRECT:
Affix
Documentary
Stamp
to be posted on the last
Signature: __________________________________________________
___________________________
Printed Name:
Designation:
License Number:
Expiry Date :
Date:
License
No / Expiry
Date

Manila
BOARD OF MIDWIFERY
PRC FORM No. 107-A


Record of Actual Intravenous Insertions
___________________________
Name of Applicant: MARK DAVID MENDIOLA TABLIZO
is:
School: OUR applicant
LADY OF FATIMA
UNIVERSITY (VALENZUELA)
Graduate Midwife
Registered Nurse
Name and Address of

Patient
1. Gemma Tumampil Agonan
29 Metro Height Culiat Quezon
City
2. Melona Mancile
1038 Del Pilar St. Makati City
3. Sonia Caya
113 Tejeros Rosario, Cavite
Case
No
586046
600548
597611
4. Marlita Eupan Role

Camp Orasan Novaliches,
Quezon City
600501
5. Rissa G. Naga
005 Bernabe Compound Pulang
Luoa, Las Pinas City
601449
Note:
Complete Diagnosis
(Gravida, Para)
(Birth weight: 3425 grams, Birth Length: 49cm), APGAR Score 8,9,
Perineal Support
(Birth weight: 2315 grams, Birth length: 50.5cm), APGAR Score 8,9,
Perineal Support
Perineal Support
Perineal Support
Perineal Support
Date &
Time
Performed

Contact Number
January 12,
2015
7:04 AM
Check if
Home
Delivery
Supervised by
Printed Name
and Contact
No.
Position /
Designation

7345561-65
Ma. Victoria A.
Barretto
09258218478
Midwife II
0133347/
August 13,
2015
January 26,
2015
4:44 AM

7345561-65
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/ April
17, 2015
January 28,
2015
10:33 PM

7345561
Rana Lorraine D.
Racca
09175876081
Midwife II
0138397/ April
17, 2015
February 9,
2015
6:15 PM

7345561-65
Ma. Victoria A.
Barretto
09258218478
Midwife II
0133347/
August 13,
2015
March 10,
2015
10:54 PM

7345561
Joebell A. Gerona
09055926156
Midwife II
0133741/
August 25,
2016
Signature

(2) For registered midwives / Clinical Instructors who supervise the student midwives and affix their signatures in this Form must present a Certificate of Training on
Intravenous Insertions to the Board pursuant to Board Resolution No. 100 s 1993, dated December 1, 1993.
SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant

exhibiting to me his/her Residence Certificate No. __________________________ issued at ____________________________ on _______________________________.
CERTIFIED CORRECT:
Affix
Documentary
Stamp
to be posted on the last
Signature: __________________________________________________
___________________________
Printed Name:
Designation:
License Number:
Expiry Date :
Date:
License
No / Expiry
Date

ATT - 1427780368982 - RM Final 2015

Загружено:

Сведения о документе

Оригинальное название

Авторское право

Доступные форматы

Поделиться этим документом

Поделиться или встроить документ

Параметры публикации

Этот документ был вам полезен?

Это неприемлемый материал?

Авторское право:

Доступные форматы

ATT - 1427780368982 - RM Final 2015

Загружено:

Авторское право:

Доступные форматы

PROFESSIONAL REGULATION COMMISSION

PRC FORM No. 106

Record of Actual Deliveries Handled

Please chec(CONTINUED NEXT PAGE)___________Health

MARK DAVID MENDIOLA TABLIZO

Name and Address of

Full Name, Address of Facility &

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

2. Lannie Napoles Albano

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Name and Address of

Full Name, Address of Facility &

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

(1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor

PROFESSIONAL REGULATION COMMISSION

PRC FORM No. 107

Record of Actual Deliveries Handled

MARK DAVID MENDIOLA TABLIZO

Name and Address of

Date & Time

Full Name, Address of Facility &

Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39 weeks, Cephalic, Right

Dr. Jose Fabella Memorial Hospital,

Name and Address of

Date & Time

Full Name, Address of Facility &

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Gravida 3 Para 3 (3003) Pregnancy Uterine 38-39 weeks, Cephalic, Left

Dr. Jose Fabella Memorial Hospital,

Gravida 2 Para 2 (2002) Pregnancy Uterine 38-39 weeks, Cephalic, Left

Dr. Jose Fabella Memorial Hospital,

4. Grace Rostata Baurosa

Gravida 2 Para 2 (2002) Pregnancy Uterine 37 weeks, Cephalic, Left

(1) For graduate midwives: Supervision must be by qualified faculty/clinical instructor

SUBSCRIBED AND SWORN TO before me this ________________________________________ at ______________________________________. Affiant

PROFESSIONAL REGULATION COMMISSION

PRC FORM No. 107-A

Record of Actual Deliveries Handled

Name of Applicant: MARK DAVID MENDIOLA TABLIZO

Name and Address of

4. Marlita Eupan Role

Full Name, Address of Facility &

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

Dr. Jose Fabella Memorial Hospital,

SUBSCRIBED AND SWORN TO before me this __ at . Affiant

SUBSCRIBED AND SWORN TO before me this __ at . Affiant