FORM 41 PHILIPPI E CIVIL SERVICE Thereby waive all rights and privileges pertaining to professional confidence between phy- sician and patient, and the physician accomplishing this form is authorized to answer in detail all questions contained herein. ¢ ignature of Patient) (N.B. Attending physician should fill in the blank below, Every deatiled should be answered to avoid delay in action on applications for leave submitted by the patient.) of the Bureau/Department of (Name of Patient) having made applications for leave of absence on account of illness, I do hereby certify that I was the applicants actual attending physicians from ,20__ to 20___, inclusive and from my professional knowledge of the case the fol- lowing statements are submitted, as contemplated by the provision of section 8 of Civil Service Rule XV Name of Disease or disability Nature of Disease or disability Under this heading in addition to giving fully etiol- ogy of tehe disease or disability the physician must either ETIOLOGY: state in the language of the Executive order: There are no indications whatever that the disease named was due to immoral or victims habits or give the indications HISTORY DESCRIPTION A laboratory test or examination was made in this, case, The applicant was confined to his/her house/hospital from . 20, , inclusive. THEREBY CERTIFY that the above statements are complete and true in every de- tail, and that in consequence of the disease or the disability above specified the applicant was ill and unable to be on duly on account of illness from » 20 to » 20. , inclusive, and that his claims is meritorious. Signature; MO ‘Name in Print: Aix Documentary Stamp | Post Office Adres Date: