DILIMAN DOCTORS HOSPITAL, INC.

251 Commonwealth Ave.,Matandang Balara, QC.

Tel No. 883-6900 – 990-3911

No.
PROMISSORY NOTE
Name of Patient : _____________________________

Date of Discharge: _____________________________

For value receive, I/we jointly and severally promise to pay the DILIMAN DOCTORS HOSPITAL the
principal amount of _________________________________________________________________________
___________________________ (P___________________) with interest charged thereon from date thereof at
the rate of 1% per month. Principal and interest shall be payable not later than _______________at your office
without the necessity for any demand made thereof.

Interest not paid when due shall be added to and become part of the principal and shall likewise bear
interest at the same rate of interest indicated hereon. In case I/we are not able to pay any or all of my account as
they fall due, the entire amount shall be immediately due without the necessity of further demand.

In case of litigation arising from this promissory note, venue of judicial proceedings shall be in proper
courts of Quezon City. The undersigned further bind themselves jointly and severally to pay the principal and
interest plus all cost, expenses, and attorney’s fees attendant to the lawsuit a sum equivalent to 25% of the total
indebtedness, inclusive of all cost or fees allowed by law. Undersigned debtors also waive the required
presentment for payment and notice of dishonour for purposes of collection.

IN WITNESS WHEREOF, we have affixed the seal of our hands, this ___day of __________ 20____ at Quezon City.

PRINCIPAL: CO-MAKER:
Signature Signature
Printed Name Printed Name
Address Address

Contact Nos. Contact Nos.

With Patient’s Conformity: Diliman Doctors Hospital

Represented by:
Printed name over signature
Government Issued ID: Printed Name & Signature
Date: Place of Issue:

ACKNOWLEDGMENT

REPUBLIC OF THE PHILIPPINES)

) S.S.

BEFORE ME, a Notary Public this _____ day of _________, 20___ for and in the above jurisdiction,
personally appeared:
NAME GOV’T ISSUED ID WITH PHOTO DATE/PLACE ISSUED

All known to me and to me known to be the same persons who executed the foregoing Agreement and they
acknowledged to me that the same is their free and voluntary act and deed as well as of the corporation herein
represented.

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