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Referral For Medical Examination - AB GONZALES YASA LOTUS

This document is a referral for a medical examination for seafarer Antonio III Ragmac Gonzales, scheduled for April 29, 2025, at SuperCare Medical Services in Manila. The examination is required for joining the vessel Yasa Diamond, and includes various medical tests as per Marshall Islands regulations. The seafarer is instructed to bring specific items and comply with health declaration requirements to avoid delays in processing the medical certificate.

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Menille Rodriguez Navalta
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59 views1 page

Referral For Medical Examination - AB GONZALES YASA LOTUS

This document is a referral for a medical examination for seafarer Antonio III Ragmac Gonzales, scheduled for April 29, 2025, at SuperCare Medical Services in Manila. The examination is required for joining the vessel Yasa Diamond, and includes various medical tests as per Marshall Islands regulations. The seafarer is instructed to bring specific items and comply with health declaration requirements to avoid delays in processing the medical certificate.

Uploaded by

Menille Rodriguez Navalta
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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REFERRAL FOR MEDICAL EXAMINATION

BSM CREW SERVICE CENTRE PHILIPPINES, INC.

PAL EMP. NO. : 437634


Seafarer : GONZALES ANTONIO III RAGMAC
Last Name First Name Middle Name
Passport No. : P0241414B SIRB : C1081280
AGE : 27 SEX : Male0 TELEPHONE # : CELLPHONE # : 63917 - 7572642
HOME ADDRESS : BARACBAC ESTEBALAOANLa UnionPhilippines2517

PURPOSE OF MEDICAL : [ X ] Joining Vessel [ ] Others:


REASON FOR LAST REPATRIATION : [ X ] End Contract [ ] Accident [ ] Sickness
IF, ACCIDENT OR SICKNESS, FINAL MEDICAL REPORT IS ATTACHED : [ ]

VESSEL : YASA DIAMOND TYPE : (TYPE) DATE : 29/04/2025


PRINCIPAL : Bernhard Schulte Shipmanagement (Hellas) SPLLC FLAG : MARSHALL ISLANDS ETD : 14/05/2025
ENGINE [ ] CATERING [ ] NEW APPLICANT [ ]
RANK : Able Bodied Seaman DECK [ X ] OTHERS [ ] EX CREW [ X ]

INSTRUCTION:
1. You are scheduled for Medical Examination on : 29/04/2025 TIME : 7:00am to 4:30pm
At: SuperCare Medical Services Inc.(MANILA BRANCH) - 573 Patria Bldg., Maria Orosa cor., Engracia Reyes (formerly Arkansas) Sts., Ermita Manila 1000
(Name and address of medical clinic)
2. Bring a thumb size of your stool in a sanitized bottle or container (Label the container with your name) or you may process it in the clinic:
3. Non-compliance of the above instructions may cause delay in the processing of your medical certificate
4. Valid Identification Card (Passport, Seaman's Book, Drivers License)
5. Be honest and truthful with your HEALTH DECLARATION (Section 20 - POEA Standard Term & Condition)
Last Illness/Accident (Pls. Specify) :
When :
I HAVE READ, understood and agreed to comply with the requirements, dated

Signature of Seafarer
Date of Last Medical Examination : Clinic :
Please conduct the DOH Basic Pre-Employment Medical Examinations, and the following medical tests as indicated below:
TYPE OF MEDICAL : MARSHALL ISLANDS REGULAR - 40 yrs old Below
REGULAR / HISTORY AND PHYSICAL EXAM, VISUAL ACUITY AND ISHIHARA, CHEST X-RAY PA VIEW, ECG, DENTAL, URINALYSIS, FECALYSIS/ROUTINE
STOOL, BLOOD TYPING, VDRL, HIV, HBSAG, AUDIOMETRY, PSYCHOMETRY
ADDITIONAL TESTS : LIVER FUNCTION TEST (TOTAL BILIRUBIN/SGOT/SGPT/GGT/TOTAL PROT/ALKALINE PHOS);
BMI LIMITS : DRY VESSELS - 18 TO 34
REMARKS/OTHER TESTS : N/A

NINA SAROCA
DATE AUTHORIZED SIGNATORY
PREVIOUS MEDICAL FINDINGS
n/a
Instruction to Clinic:
* Please send billing to JAYSON P. DAVID
* Requesting release of medical results and medical examination report of the referred crew
* DENTAL BRACES STRICTLY NOT ALLOWED

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