Marissa Lukban Pre-Clinic Appointment Form 
Thank you for your interest in consulting with Dr. Marissa Lukban (Child Neurologist)
ON LEAVE JAN 7,2026 to JULY 7, 2026 (teleconsultationS only) 

*** Prescriptions for PDEA regulated drugs like Phenobarbital and Clonazepam needs to be picked up at the clinic.***

You have two options for an appointment.
A. ONLINE TELECONSULTATIONS preferably between 11am - 2pm daily.  If not available during office hours, may schedule from 8-9pm on limited days
B. FACE TO FACE CONSULTATION (BY APPOINTMENT) - temporarily not available
1) every MONDAYS, 3-5PM and SATURDAYS from 1-4 PM at PGH FMAB SECOND FLOOR PEDIA COMPLEX ROOM 205 
2) every MONDAYS and SATURDAYS from 8-12 noon at CAPITOL MEDICAL CENTER (PREFAB BUILDING) MULTISPECIALTY CENTER (former Dialysis Unit, beside HYUNDAI along Quezon Avenue) (02) 8-3723825 loc 1250 or 09190691891 to 92 

To facilitate the consultation, KINDLY FILL UP THIS FORM and indicate in the google form your PREFERRED MODE (TELECONSULTATION OR FACE TO FACE) and PREFERRED DATE AND PLACE OF APPOINTMENT.
*Contact secretary CARLA 0943-0278987(Viber)  for questions. She will also confirm your appointment request. 

Let me emphasize that FACE TO FACE CONSULTATION is still the best option for clinical evaluation and has resumed in my PGH FMAB clinic and in CAPITOL MEDICAL CENTER MULTISPECIALTY clinic  preferably by APPOINTMENT BASIS thru this form. 

For teleconsultations, this is done through the Zoom app which is downloadable from Play Store for Android or Apple Store for Mac. Filling up the appointment for teleconsultation thru this form implies that you CONSENT to this mode of consultation and all its implications. Please be reminded also that your privacy is important and I will ensure compliance with the Data Privacy Act. In the same manner, it is prohibited for you to record, take a picture or a screenshot of the teleconsultation, under penalty of law, without my consent. I will send you a link to the Zoom Meeting ID through your e-mail/cell/viber number. The consultation fee of 1000 pesos can be paid online prior to the consultation. This will include the issuance of new prescriptions if needed. The billing details will be sent to your e-mail or cell/viber numbers.  Please remember also to email a copy of the confirmation of payment for the teleconsultation.

If you have any additional questions, please feel free to contact me thru my email at marissa.lukban.telemedicine.pna@gmail.com

Thank you.

Sincerely,
Dr. Marissa Lukban
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