.&.n .

/fL-i.ln~A

.~

HOSPITAL

'I J 1 .:I

~ LS.I.&&.I

Lie No. 14-101-10-12-002

\t - ,.,

02041

.1c" n

- ,. - H - ~:~J ~

Jl

.l~

U' 9 et

~U

: ~l.w:tJ

:tJ ~\ ~

( " ) ~.J ~ j.,...;

KINGDOM OF SAUDI ARABIA

MINISTRY:

~.)04

oj~~ ~j~

SICK LEAVE REPORT

A~~r.- J~\~

Patient Name :
Medical Record No. :

I.k..l ..~.~.~~....

-B-M OF
Nationality :
Date of Birth :
Occupation :
Place of Work:
Date of Visit :
Adm. Date :
Discharge Date :

:~
..

w..I0.~.~,~.'}Jt'.~~!')
:~

: 4-JI
: J.oall ~
~:':.::-.~
..: ..~.<?L~.................
~.~.::.?:-..~\:-.......................

-'
-'

/
/

/
/

!3.1.::~ Q.~.::.?:!=?!A...................

-'

/ : ~~

/O't.tf

: ~I~I
: JJ......i..llI

~
~

in

~'cA.f'~.J

-d~

-~ ~

~I

~.JA

tUl day(s)

~D

iJ.J ~jO'..P.!

1.(/9/;~.YI9!!~

-' / /

starting from
FOllow-uptbJ~re end of sick leave
Referral to Medical Committee for

vl! -'

:~

o
o
o Permanent or partial disability

()o

('41/ ('-'4(
)
~
~ljOD
~ vl! ~!

i~1

: ~~! ~~ J:.i ~
~
Ja.~ t..w\ ~

following reasons
Approval of sick leave
Cannot be treated at this facility .

D Others:

tlJ

;.~

~.~.~~

Following medical examination, it is recommended

~D~jD

Recommendation

o Sick leave for

:~

~I

.~~~ID
:~

.~.,i
.

~~

vi ~

J.oalI r:p

i~

t.r-l'.~ ~

.......................

T~eatingPh~:
~ :
Signature :.~NO.:
Physician Name:
Signature:
Approval by the Director of :
Name:
Signature:
Date:

.
.
.
.
.
.
.

us-n ..>#-

()oD

J~..:.Ila.D

: (,$~I

:~~~I
tl.)1

~~

:~~I

..

.. ............................................

: ~

~~
J:I~

: ~'il

-'

:~

:~,,:;.n

('~

;,a:.-' /

~. ~

:tl.; ~
~! i.;Wo!
.~I ~~.,..n ~ ~ ~
~ d4
.~I ,,--It:-.' ..11...L.ll
Uli
..
1I4-1
11i .UI
r:r
'-'.
jO cr: J-.
~.,

.;Jl-lI Jo'.fol\ ~

...................................................
...................................................
................................................

w~

~
:~
:

: ~~