PHILIPPINE CIVIL SERVICE

MEDICAL CERTIFICATE
I hereby waive all rights and privileges pertaining to professional confidence between physician and
patients, and the physician accoplishing this for is a!thori"ed to answer in detail #!estion contained herein$

Signat!re of Patient

%ttending physician sho!ld fill in blan& below, every detail sho!ld be answer to avoid delay in action an
application for leave s!bitted by the patient
'Patient(
of the b!rea! on acco!nt of illness I do hereby certify that
incl!sive and fro y professional &nowledge of the case the following stateents are s!bitted as conteplated
by provision of Section ) of Civil Service *IV$
Nae of disease or disability
Nat!re of disease or disability

+nder this heading, in addition to giving f!lly the etiology of the disease or disability, the
physician !st either state in Lang!age of the E,ec!tive -rder. /0here are no indications
whatever that the disease nae was d!e to ioral or vicio!s habits1 or give the indication$


HIS0-R2

3ESCRIP0I-N


% Laboratory test e,aination in this case
0he applicant was confined to her4his hoe4hospital fro , 56
to , 56

I HERE72 CER0I82 that the above stateent are coplete and tr!e in every detail, in that in
conse#!ence of the disease or disability above specified the applicant was ill !nable to be on d!ty on acco!nt of
illness fro , 56 to , 56 incl!sive and that his4her clai is
eritorio!s$
'Signat!re( 9$3$
'P$-$ %ddress(
E0I-L-:2